Draft: Request to central administration
For your request, please leave the information below
(01) Full Name of the requestinc: clinic / hospiatl university
(02).1 Name of the department:
(02.2) Street / City Zip-Code / Country /
(03) Contact person in chrage of the request:
(04) Medecal responsible doctor:
(05) size and type of buffer bag 25 ml / 100 ml:
(06) ammount of bags (f. ex 10) :
(07.1) fully delivery address,
(07.2) person for contact with courier service:
(08) controling departmet /invoice managment:
(09) Reference: Please refer to your written prescriptio:
example: [RZPT_DDMMJ_Buffer_Request_Prescription_DT]
placed in the HIDRIVE as signed pdf.
300925 function test
(01) transmitting e-mail
result : approved 30.SEP .2025