Under certain circumstances (f.ex regular follow up) our patients have the possibility to order a repeat prescription for a chronic or recurrent treatment. Please specify whether the prescription is to be sent home or will be picked up at the medical center. The medical center MG Echternach reserves the right to modify your prescription renewal inquiry.

date_time

Open the calendar

id

Title

Please select… Mr Mrs Divers

First name

Family name

Social security number (Matricule)

Phone number

E-Mail

Concerns

Please select… Chronic treatment Other

Delivery

Please select… Send by mail Pick up at the secretariat Pick up at the letter box

Attending doctor

Please select… DR. HOFFMANN Philippe DR. LAMPACH Daniel DR. VERVOORT Anne-Catherine

Medicament

 

 

I confirm my agreement that the medical center MG Echternach 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