Order a medicament

First name

Surname

Date of birth (DD.MM.YYYY)

Street / Number

Postal code / Location

Phone

E-mail

Your insurance company

Your insurance policy number

Medicament(s)

I will collect the medicament in the private practice (no additional fee)
I would like to have a prescription by email
I would like to have a prescription by mail

We will contact you in the following days.

Data privacy statement

I hereby agree, that asantae saves the information for the further correspondence.
For the complete data privacy statement see here.