GESUNDHEITSZENTRUM FÜR DIE FRAU
With this form you can order your medicine or birth control pill and tell us when you'd like to pick up your order.
Are you a patient already?
*
Yes, I am a gynosense patient.
First Name:
*
Last Name:
*
Date of Birth:
*
YYYY-mm-dd
Email address:
*
Name and dosis of your medicine / pill:
*
e.g. Desoren 20, Euthyrox 75
Medicine: Packaging size
Birth control pill: For how many months?
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months
11 months
12 months
When would you like to pick up your order? (day + time)
*
Please note for orders to be picked up on the same day please inform us before 10 AM. – ATTENTION! Holidays. 21st Dec. to 2nd Jan. No pick up possible.
Your phone number:
Would you like to send us an additional message?
