Prescription order | Medizinisches Zentrum Erlangen

Order permanent medication

Only permanent medications of our patients can be ordered online. Medications that are not yet registered in your file (for example, because they were previously prescribed by a pulmonary specialist) can not be obtained via this form!

Your complete name

First & last name

Your date of birth

Birthday, month of birth, year of birth (dd.mm.yyyy)

Your phone number

Voluntary indication

Your e-mail address

My health insurance recently changed

No Yes

Health insurance

Insured person number

Status

medicament or transfer form

Drug with indication of mg number
You can also order multiple medications
Transfer form stating the specialty

Pickup

I agree that my data will be transferred to the general practice of Dr. Forberg & Dr. Walter and used there for the above-mentioned purpose. I have taken note of the data protection declaration and the information on data protection. (Please tick!)I agree and have taken note of the data protection information.

Submit

Notes on data protection

The following contact form is used to order permanent medication in the general practice. We need the field name /patient number and year of birth to clearly identify you and to avoid confusion. We need the e-mail address in case of questions regarding the prescription order. If your request is not needed for documentation purposes, all transmitted data will be deleted after answering.

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Medication online order