General Practitioner since 1979

Tel. 0761 / 404 404

Dr Rusteberg's shingle outside the general practitioner's office

Contact

Hexentalstr. 4A
79249 Merzhausen

Tel. 0761 / 404 404
Fax: 0761 / 406 280
doktor@rusteberg.de
www.doktor-rusteberg.de

Contact information: Name:
Phone number:
Mandatory field Email:*

I'd like to ask for the following: Referral to a medical specialist

Field of specialisation:
because of the following ailment/diagnosis:

Referrals are supposed to be

deposited in the practice's mail box (fastest way and free of charge)

sent (2€ flat charge)

to my private address (delivery time 1 to 5 days)

to the following doctor's office (by mail or fax)

Prescription:

for the following drugs:
Please specify the internal number, if possible:

Prescriptions are supposed to be

deposited in the practice's mail box (fastest way and free of charge)

sent (2€ flat charge)

to my private address (delivery time 1 to 5 days)

to the following pharmacy (by mail or fax)

Appointment:

at 0:30 pm on
at 7:00 pm on
Desired date (time and day):

Consultation by phone

Please indicate 3 preferred points of time for callback:

Callback time 1
Callback time 2
Callback time 3

Consultation via internet

concerning the following issue (keywords only):

Other

Please note: you may regard your request as processed as soon as you have received a mail read confirmation or an "OK" from us. If you receive none of those, please listen to our answering machine. Thank you!

Yes, I'd like to get a copy of my request to the email address entered above!

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