Order medication - Zuidasapotheek.com

Name*

First Last

Date of birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone*

E-mailaddress*

Name of your GP*

I receive the medication*

Every 3 months
Every months

I agree that my general practitioner and pharmacy provide the relevant data for my medicine use.*

Yes
No (we can not offer the repeat service for this choice)

I get a message when the medicines are ready for me. These medications ..*

I pick up in the pharmacy
I would like to receive home delivered

I will pass on changes in my medicine use to the pharmacy so that it is aware of my current medication use.*

yes
No (unfortunately we can not offer the repeat service with this option)

I will inform the pharmacy of medication that I have taken in another pharmacy.*

Yes
No (unfortunately we can not offer the repeat service with this option)

For the correct start-up of this service, it is important that the pharmacy knows exactly how much stock is left from the daily medication at home.

The date on which I counted my medication.*

Medication name*

Number of pieces per day*

Quantity in my stock*

Medication name

Number of pieces per day

Quantity in my stock

Medication name

Number of pieces per day

Quantity in my stock

Medication name

Number of pieces per day

Quantity in my stock

Medication name

Number of pieces per day

Quantity in my stock

Medication name*

Number of pieces per day

Quantity in my stock

Medication name

Number of pieces per day

Quantity in my stock

Medication name

Number of pieces per day

Quantity in my stock

Do you not have enough room for all medicines above, or do you have any questions or comments? Then you can note this in the field opposite.

Wanneer ik op 'verzenden' klik ga ik ermee akkoord dat de Apotheek tot wederopzegging de herhaalservice in overleg met mijn huisarts voor mij opstart.

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Register for a repeat service at the Zuidas pharmacy