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.
Please send to CURRENT mail / home delivery address (select only if no children or pets can access mailbox and accidentally swallow medication)
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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