Family Practice Dr Samsom
www.samsomhuisarts.com


To request for a repeat prescription you can fill out and send us the online form below. If you send the form before 14.00 hrs, you can already pick up your medicines the next working day, at your local pharmacy.


Request for repeat prescription(s)

Surname:

Initials:

Gender:

Date of birth:

Zipcode:

Address + House no.:

Telephone:

Email address:

Name of your pharmacy:

Please indicate below for which medicines you would like a repeat prescription. Please also state: the dose, how often a day you use the medicine and how many pieces you want.