Prescription Request
Please fill in the form completely.
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Request will be sent to
Studio medico Al Parco
Step 1: Patient data
AVS / AHV Number
*
Format: 756.0000.0000.00
Invalid AVS number. Format: 756.0000.0000.00
Step 2: Physician
Physician
*
Please select…
Required
Step 3: Request by
Request from
*
Patient
Pharmacy
Step 4: Requester data
If requested by the patient, no additional requester details are needed. Data and email will be taken from the patient record.
Pharmacy name
*
Required
Employee name
*
Required
Pharmacy email
*
Please provide a valid email for prescription delivery.
Send a confirmation email to this address
Step 5: Medications
Medications
+ Add medication
Request date
Comment (optional)
Save my information (cookie)
I agree that my details are stored on this device in a cookie for 180 days.
Step 6: Review and submit
Please review all details before submitting.
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Search medication
*
Please enter a medication name.
Boxes
*
Quantity: 1–10