Prescription

Your name/name of the child *

Your email address *

Date of birth/your child *

Street and House number *

ZIP Code and City *

Phone*

Subject

Your message

I need follow-up recipes for the following medications:

As you know, we have to check you/your child regularly because of medication. Please contact us for a follow-up appointment if you have not visited us for more than 6 months. Please contact our registration office by telephone at 0611-9310972.

I agree with the Privacy Policy too*.

This form stores your name, email and phone number only to process your prescription order. For more information, please see our current privacy policy.

By agreeing to the current privacy policy, you confirm that the private practice Drs. Med. Elisabeth Aust-Claus/Dr. Med. Dieter Claus can receive your name, date of birth, telephone number and e-mail address and save it temporarily.

For security reasons, ask them to enter the following characters in the adjacent field so that your request can be sent. Thank you very much.

For security reasons, the privacy policy must be approved in order to be able to send your request!

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