Under certain circumstances (f.ex regular follow up) our patients have the possibility to order a repeat prescription of chronic or recurrent treatment. Please specify whether the prescription is to be sent home or will be picked up at the medical center.

×

id

date_time

Title

Please select... Mr Mrs

First name

Last name

Phone number

E-Mail

Insurance number (Matricule)

 

Subject

Please select... treatment other

Delivery

Please select... send by post pick up at the practice

Attending doctor

Please select... Dr Danièle HOLPER Dr Jean-François MICHEL Dr Siggy RAUSCH Dr Marie-Josée WIRTGEN-BESCH Dr Steve HEIN Dr Florence KEIPES

Medicine

 

I confirm my agreement that Steinsel medical center treats my personal data for the purpose of a repeat prescription according to the GDPR.

 

I declare that I have read the privacy statement and accept the conditions.

Submit