homedownloadsenquiries@ctonlineclinic.com
A prior consultation in one of our clinics is required before a doctor can prescribe medication for:

• Insomnia • Pain relief • Anxiety • Impotence
Personal Details:
Forenames:
Last name:
Telephone:
Registration Number:
(if known)
Initials:
Date of Birth:
Email Adr:
Prescription Request:
Is prescription to be posted?

Name of Medication
(please make sure that this medication is correct)

Strength of medication

Quantity required

* At Doctors Discretion
Has there been any change in your medical history since your last prescription?
Are you getting the same medication from another source?
Payment Due 10,00 €
Payment Details:
In person
Cheque, by post
Cheques should be made payable to “Dr Bernard Willis ”
By ASSSA or ARESA Insurance:

Please send to:
Clinica Tarraula
Cami Cabanes TA83
03739 Javea
Alicante

Please remember that none of your personal details will be sent to any third party under any circumstances.