Shengenintyg
Contents
1. Autorit qui d livre authentific biffer ce qui ne convient pas d signation adresse t l phone sceau signature de l autorit2. de P Accord de Schengen 1 country town date ays d livr date y pay Prescribing doctor name first name phone address in cases of issuing by doctor stamp signature of doctor Patient name first name no of passport or other identification document place of birth date of birth nationality sex address duration of travel in days validity of authorisation from to max 30 days Prescribed drug trade name or special preparation dosage form international name of active substance concentration of active substance instructions for use total quantity of active substance duration of prescription in days max 30 days remarks Issuing accrediting authority deleate no applying expression address phone stamp signature of authority M decin prescripteur nom pr nom t l phone adresse en cas de d liverance par un m decin cachet signature du m decin Patient Nom pr nom n du passeport ou du document d identit lieu de naissance date de naissance nationalit sexe adresse dur e du voyage en jours dur e de validit de l authorisation du au max 30 jours M dicament prescrit nom commercial ou preparation sp ciale forme pharmaceutique d nomination internationale de la substance active concentration de la substance active mode d emploi quantit totale de la substance active dur e de la prescription en jours max 30 jours remarques
3. Ah L KEMEDELSVERKET MEDICAL PRODUCTS AGENCY Intyg f r medf rande av narkotikaklassat l kemedel inom ramen f r medicinsk behandling enligt Schengenkonventionens artikel 75 Sverige Land A F rskrivande l kare Efternamn F rnamn Telefon Adress L karens namnteckning B Patient 5 6 Efternamn F rnamn Passnummer 7 8 F delseort F delsedatum 9 10 Nationalitet K n 11 Hemadress 12 Fr n till 13 Resans l ngd i dagar Tillst ndets giltighetstid max 30 dagar C F rordnat l kemedel 14 L kemedelsnamn L kemedelsform 16 Verksam substans internationella namn Styrka 18 Dosering Total m ngd av verksam substans 20 Behandlingens varaktighet under resan max 30 dagar Anm rkningar D Intygande myndighet L kemedelsverket 22 23 Box 26 SE 751 03 UPPSALA Tel 46 0 18 174600 24 Myndighet ens st mpel och underskrift Bilaga Intyg f r medf rande av narkotikaklassat l kemedel inom ramen f r medicinsk behandling enligt Schengenkonventionens artikel 75 Certification to carry drugs and or psychotropic substances for treatment purposes Schengen Implementing Convention Article 75 Certificat pour le transport de stup fiants et ou de substances psychotropes des fins th rapeutiques Article 75 de la Convention d application
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