Full Name*
Date of Birth*
Contact Number*
Have you spoken to the doctor(s) or attended our practice within the past 12months?* YesNo Script may not be issued without a medication review.
Medications Requested* (Name, strength and frequency of ALL medications is required, or prescription request can not be processed)
Repeat prescriptions should be requested at least 72hours before they are required, and will be sent electronically to your pharmacy. On occasion, you may be asked to see the doctor, so that medications can be reviewed. (There is a repeat prescription fee of €25, unless you are a Medical/Doctor Visit Card holder).
Privacy Policy We will use your data above to process your prescription. We will not use your data for any other purpose. I consent to you collecting my details
