Useful Forms

This section provides links to various forms our patients and medical team find useful to access throughout the year.

Main Street Clinic Order Forms

• Repeat Prescription
  Use this online form to order repeat prescriptions
• Social Welfare & Private Certificates
  Use this online form for ordering continuation of social welfare certificates and private certificates

Forms to Complete Prior to Appointment

• Form to Complete Prior to Menopause Review
  Before your visit to the clinic for a menopause review, please complete and submit this form prior to your appointment

National Healthcare Application Forms

• HSE PRIMARY CARE SCHEMES APPLICATIONS
  • Medical Card / GP Visit Card
  • Drug Payment Scheme
  • Carers GP Visit Card
• ILLNESS/INJURY BENEFIT
  • To apply for Illness Benefit: Submit an online Illness Benefit application through MyWelfare or post an IB1 Form (application form for Illness Benefit and Injury Benefit available at the clinic) to the department. Details available here.
• MEDICAL CARD:
  • Medical Card Application – MC1 Form (Source: HSE)
  • Medical Card – Change of GP Form (Source: HSE)
  • Applying for HSE Primary Care Schemes: Medical Card
• GP VISIT CARD
  • GP Visit Card – Change of GP Form (Source: HSE)
  • GP Visit Card – Over 70s (Source: HSE)
  • GP Visit Card – Under 8s (Source: HSE)
• CARERS:
  • Carer’s Benefit Scheme – CARB1 Form (Source: Social Welfare Services)
  • Carer’s Allowance Form – CR1 Form (Source: Social Welfare Services)
  • Applying for HSE Primary Care Schemes: Carers GP Visit Card
• DRUG PAYMENT:
  • Applying for HSE Primary Care Scheme: Drug Payment Scheme
  • National Drugs Payment Scheme Application Form (Source: HSE)
• MEDICAL REPORT
  • National Driving License Medical Report Form (Source: NDLS)
  • Driving Licence Eyesight Report Form (Source: NDLS)
• DISABILITY ALLOWANCE
  • Disability Allowance Application Form – DA1 (Source: Social Welfare Services)
• MATERNITY BENEFIT
  • Maternity Benefit Application Form (Source: Dept of Social Protection)
• LONG TERM ILLNESS
  • Long Term Illness Scheme Application form (Source: HSE)

Europe-Wide Healthcare Application Forms

• Disabled Drivers EU Parking Permit Application form (Source: DDAI)
• European Health Insurance Card (EHIC) / Travel Card Application Form (Source: HSE)

Tax Refund Forms – Medical & Dental Expenses

• Medical Expenses Tax Relief Revenue Commissioners Ireland
  The Med 1 is no longer available. Health expenses are claimed through your Income Tax Return. If you are a Pay As You Earn (PAYE) taxpayer, you also have the option to claim relief in real time during the year. You can claim relief on health expenses through myAccount or Revenue Online Service (ROS).

GDPR Consent

• Consent Form for Release of Patient Information (PDF)
  Letter of consent for release of patient medical records to Hospitals / Clinics / Consultants or other services etc
• Subject Access Request (SAR) Form
  Source: Dept of Enterprise, Trade & Employment