Medizinische Hochschule Hannover : Lorem ipsum dolor

Prescription request pain outpatient clinic

Surname: *

First name: *

Date of birth: *

Gender: *

e-mail address: *

My address:

Telephone number: *

Insurance status: *

Please name your:n most recent:n practitioner:in the pain outpatient clinic of the MHH:

Prescription requests: *

I would like the prescription to be delivered to the above address: *

We can process prescription requests from Tue-Thu. Please remember to order your medication in good time - at least two weeks before your medication runs out. Prescription requests at the weekend (Fri-Sun) will only be ordered on Monday.

Prescriptions and orders can be sent to you by post to the above address if you have a valid referral for the quarter. An EXCEPTION to this are BTM prescriptions and prescriptions for cannabinoid therapy.

In this case, we will arrange a collection appointment with you (e-mail/telephone). Please give us a contact so that we can reach you to arrange a collection appointment.

Your contact:

Please note that BTM prescriptions must be redeemed within seven days of issue.

If you have any queries or problems, please contact us by e-mail: schmerzambulanz@mh-hannover.der

I hereby confirm that I am not undergoing inpatient treatment or rehabilitation. *

I have taken note of the information obligations (* see text below the form), which inform me in full about the use of the data provided via the contact form. *