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Terms
All fields which contain
*
are required.
Applicant / Care Agent
*
Name
*
Email
*
Phonenumber
*
Organization
Care Team
*
Team Name
*
Phone Nr.
*
Email
Organisation
*
Type of care
Make a choice
Home care
Rehabilitation
Institutional Care
Client
*
Salutation
Mr.
Mrs.
*
Initials
*
Last Name
*
Date of Birth
*
Address
*
Zipcode
*
City
*
Phone Nr.
*
Has hand over medicine indication?
Yes
No
Delivery Adress
*
Delivery
At the client.
Somewhere else:
*
ATTN
*
Address
*
Zipcode
*
City
*
Phone number
Pharmacy
*
Name
*
Address
*
City
*
Clients ID at Pharmacist
Medication
*
Start Date First Roll
*
Block Early Dispense
Yes
No
Add schedule
Add a new moment (hh:m0):
Remarks
*
The client grants all parties involved, namely the pharmacy (and its medication packager), Medido and its subcontractors, permission to share data from this registration form and information about medication moments solely for the purpose of pharmacotherapeutic treatment. These data will not be used for other purposes or disclosed to third parties without the client's consent. The medication dispensed by Medido and taken independently by the client is entirely under the client's responsibility.
Medido gebruiksvoorwaarden
The client declares to agree with the above conditions and requests the care team to activate this request with Medido.
Yes
No
Request Medido