Extending a prescription

On the basis of the form, a physician will issue a prescription.
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.

This field is required
This field is required
This field is required - digits only
Please provide your correct email address
This field is required
This field is required
This field is required
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
You can add multiple files

Nieprawidłowe dane

 

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

Nieprawidłowe dane
Required field
This field is required
This field is required
Nieprawidłowe dane
This field is required
This field is required
This field is required
This field is required
The consent is required
The consent is required