Przedłużenie recepty

Extending a prescription

On the basis of the form, a physician will issue a prescription in max 7 days.
The e-prescription code will be sent by mail.
This service is available only to the Derm-Al patients who are undergoing treatment.

Note

In some cases (e.g. Isotretinoin treatment), an e-prescription will not be issued, if relevant test results are not enclosed to the request. The physician will decide whether a patient can continue taking medication without a visit at the Centre.

1. I would like to ask for a prescription from the physician*

This field is required

2. Patient’s first and family name*

This field is required

3. Patient’s PESEL number*

This field is required - digits only

4. Your e-mail address:*

Please provide your correct email address

5. Your phone number*

This field is required

6. I declare that I am*

Patient/Patient’s parent/Patient’s legal guardian

Person authorised by the patient. If you select this option, you must enclose a scan or picture of your authorisation. You can download a standard form of such authorisation here >>

This field is required

7. Name of the medication*

This field is required

8. The reason why the e-prescription is needed*

Required field

9. It is recommended to enclose pictures, test results or other information
In the case of patients who are currently on Isotretinoin, it is required to enclose the following test results after the first month of application and then after every two months: ALAT, ASPAT, lipid profile, plus for women, every month: Beta HCG.

jpg/png/pdf files
Max. size 5MB
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Nieprawidłowe dane

10. Fill in the fields below, if you want to receive an invoice

I do not need an invoiceinvoice issued to a natural personinvoice issued to a company Nieprawidłowe dane

First and family name*

Required field

Company name*

This field is required

NIP (tax) number*

This field is required

ulica*

Nieprawidłowe dane

This field is required

I confirm that all the information provided by me is true. * The consent is required

I confirm that I have read and accept the provisions of the Contract and the Terms and Conditions of the Provision of Consultations by Electronic Means by: Centrum Dermatologiczno - Alergologiczne „Derm-Al” Sp. z o.o. * The consent is required

I confirm that I have read and accept the GDPR privacy policy of Centrum Dermatologiczno - Alergologiczne „Derm-Al” Sp. z o.o. * The consent is required

Extending a prescription

Note

contact

Contact

Dermatology and Allergy Centre Derm-Al Sp. z o.o

Derm-Al Beauty

Team

Treatments

INDICATIONS

We accept medipacks

We accept credit cards

Installment payments

Extending a prescription

Note

contact

Contact

Dermatology and Allergy Centre Derm-Al Sp. z o.o Derm-Al Beauty

Team

Treatments

INDICATIONS

Dermatology and Allergy Centre Derm-Al Sp. z o.o

Derm-Al Beauty