International Doctor’s Letter for Patients in OST –
Opioid Substitution Treatment
To
whom it may concern
Date:
Topic:
Doctor’s Letter / Medical Certificate
Mr./Mrs.
Date
of birth:
Address:
Diagnoses:
is taking D-L-Methadone / Levo-Methadone
/ Buprenorphine/Codeine for his/her medical condition and his/her current dose
is mg (
) with daily/weekly clinic/pharmacy attendance.
According
to our national laws he/she has been provided with daily doses (
) for a journey to ......
Date
of arrival at........................
Date
of departure:..........................
Further
medication:
Take
out regulation in our clinic:
Notes:
In
case of questions please do not hesitate to contact me.
Sincerely