Prescription Request Form

(dd-mm-yyyy)
Medication 1
Medication 2
Medication 3
Medication 4
Are you a registered IHCH patient and has this medication been prescribed / dispensed by the IHCH pharmacy in the past?
If no, a consultation with a doctor is required before your request is processed. Please submit this form and an assistant will call you to schedule an appointment.
Can you pick up the medication from the IHCH Pharmacy?
Service not possible for opiates/controlled substances
** If order should be sent to another pharmacy, please state name, address and fax number
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