Script Renewal Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name and Surname *ID Number / Date Of Birth *Email Address *Mobile Number *Please select your doctor:Dr. Ilsa (Micky) OrreyDr. Nicolina BardouWhen last did you see your doctor?About 1 month agoAbout 3 months agoAbout 6 months agoMore than a year agoFor ORAL medication (PILLS / CAPS / TABLETS) - specify the NAME of the medication:For ORAL medication (PILLS / CAPS / TABLETS) - specify the DOSAGE of the medication:For TOPICAL medication, please specify NAME of medication:For TOPICAL medication, please specify if:CreamGelLotionOintmentSprayHow many REPEATS would you like the doctor to issue?30 days2 months3 months6 monthsIs there any additional information you would like to add for the doctor?Submit
