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