GSM nummer*	+ Internationaal formaat, bv:: +32476123456
Naam van uw geneesmiddel**
Kleur van de geneesmiddel optioneel
De inname begint op**	dag 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / maand Januari Februari Maart April Mei Juni Juli Augustus September Oktober November December / jaar 2002 2003 2004
Duur van de inname**	Kies de duur van de behandeling ___________________________ 1 Dag 2 Dagen 3 Dagen 4 Dagen 5 Dagen 6 Dagen 7 Dagen 8 Dagen 9 Dagen 10 Dagen 11 Dagen 12 Dagen 13 Dagen 14 Dagen 15 Dagen 16 Dagen 17 Dagen 18 Dagen 19 Dagen 20 Dagen 21 Dagen 22 Dagen 23 Dagen 24 Dagen 25 Dagen 26 Dagen 27 Dagen 28 Dagen 1 Week 2 Weken 3 Weken 4 Weken 5 Weken 1 Maand 2 Maanden 3 Maanden 4 Maanden 5 Maanden 6 Maanden
Uur van de herinnering** Druk op 'add' om een uur te kiezen.	_____
De frequentie**	Kies de frequentie ___________________________ Dagen      Elke dag      Elke 2 dag      Elke 3 dag      Elke 4 dag      Elke 5 dag      Elke 6 dag      Elke 7 dag ___________________________ Weken      Elke maandag      Elke dinsdag      Elke woensdag      Elke donderdag      Elke vrijdag      Elke zaterdag      Elke zondag
Uw land**	België Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Argentina western prov Armenia Aruba Australia Australian Captial Territory Australia Lord Howe Island Australia New South Wales Australia Northern Territory Australia Queensland Australia South Australia Tasmania Australia Victoria Australia Western Austria Azerbaijan Azores Bahamas Bahrain Balearic Islands Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Brazil Acre Brazil Atlantic Islands Brazil East Brazil West Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Atlantic Canada Central Canada Eastern Canada Mountain Canada Newfoundland Canada Yukon & Pacific Canary Islands Canton Enderbury Islands Cape Verde Caroline Island Cayman Islands Central African Rep Chad Channel Islands Chatham Island Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic EAST TIMOR Easter Island Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Lslands (Malvinas) FAROE ISLANDS Fiji Finland France Franch Stouthern Territories French Guiana French Polynesia Gabon Galapagos Islands Gambia Gambier Island Georgia Germany Ghana Gibraltar Greece Greenland Greenland Scoresbysun Greenland Thule Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Honduras Hong kong Hungary Iceland India Indonesia Central Indonesia East Indonesia West Iran, Islamic Republic Of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kusaie Kuwait Kwajalein Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic Of Madagascar Madeira Malawi Malaysia Maldives Mali Malta Mariana Island Marquesas Islands Marshall Islands Martinique Mauritania Mauritius Mayotte Melilla Mexico Mexico Baja Calif Norte Mexico Nayarit Mexico Sinaloa Mexico Sonora Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Hebrides New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pingelap Poland Ponape Island Portugal Puerto Rico Qatar Rep. Dem.Of Congo - Haut Zaire Rep. Dem.Of Congo - Kasai Rep. Dem.Of Congo - Kinshasa Mbandaka Rep. Dem.Of Congo - Kivu Rep. Dem.Of Congo - Shaba Reunion Romania Russian Federation zone eight Russian Federation zone eleven Russian Federation zone five Russian Federation zone four Russian Federation zone nine Russian Federation zone one Russian Federation zone seven Russian Federation zone six Russian Federation zone ten Russian Federation zone three Russian Federation zone two Rwanda Saba Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Society Island Solomon Islands Somalia South Africa Spain Sri Lanka St Christopher St Croix St John St Maarten St Thomas Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Tahiti Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad and Tobago Tuamotu Island Tubuai Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay USA Alaska USA Aleutian USA Arizona USA Central USA Eastern USA Hawaii USA Indiana East USA Mountain USA Pacific Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgins Islands, U.S. Wallis And Futuna Windward Islands Yemen Yugoslavia Zambia Zimbabwe GMT-1 GMT GMT+1

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