Walk-in client

With this form, you are registering with our pharmacy: welcome)!

Initials

Family name

Country code

Phone number

Email address

Do you have any medicine or bulking agent allergies

Remarks

I am aware that by obtaining medication from this pharmacy, I enter into a treatment agreement with the pharmacist. They are thereby obligated to provide me with proper care. What this entails is stipulated in the Dutch Medical Treatment Agreement Act (WGBO). The duties you have as a patient are also outlined in this law. Click here for more information.

I have provided all relevant medical information to the pharmacy, and I understand that I am responsible for informing my own doctor and pharmacist about the treatment I receive

I agree to the processing of my data

CAPTCHA

Deze vraag is om te controleren dat u een mens bent, om geautomatiseerde invoer (spam) te voorkomen.