Performance request for reserved procedures Drs. An van Veen (Performance code 24200, AGB code: 84021556, AGB clinic: 90064562) (copy)

Name: Performance request for reserved procedures Drs. An van Veen (Performance code 24200, AGB code: 84021556, AGB clinic: 90064562) (copy)
SKU: MED100-1
Price: 50.00 EUR
Availability: InStock

€ 50,00

Performance code 24200, AGB code: 84021556, AGB clinic: 90064562

Requesting repeat prescription

Email address

Name

First name Surname

Date of birth

RECEPTIONS

I have had a consultation at BeterKliniek for the past six months?

Yes

No
If you have not had a consultation in the past year, you will be charged for a consultation if you continue with this form. You may still schedule the consultation the next month at no charge

I agree to pay €19 for the repeat prescription

Yes

No

Nothing has changed in my health condition since the last prescription?

That is correct

That is not correct

Based on the information you provided, you cannot request a repeat prescription. Please contact us during the free patient consultation hour: 040-7117337

Medicine

Enter the name of the drug here

Dosage

Enter the dosage e.g. mg or ml

Number

Enter the desired number

Unit

Medicine

Enter the name of the drug here

Dosage

Enter the dosage e.g. mg or ml

Number

Enter the desired number

Unit

Medicine

Enter the name of the drug here

Dosage

Enter the dosage e.g. mg or ml

Number

Enter the desired number

Unit

Note

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Subtotal

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Total

Request for performance of reserved acts Drs. An van Veen (Performance code 24200, AGB code: 84021556, AGB clinic: 90064562) (copy) number

Article number: MED100-1 Category: No category

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Performance request for reserved procedures Drs. An van Veen (Performance code 24200, AGB code: 84021556, AGB clinic: 90064562) (copy)

Requesting repeat prescription

RECEPTIONS

DOE EEN DNA-TEST!

Call me back for a free informational interview