Repeat Prescription Ordering

Use this form to order repeat prescriptions. Please allow 48 hours before you collect same in your pharmacy. Where necessary, patients may be requested to attend their GP where medication or condition needs to be reviewed. In such instances, the prescription will be deferred until this consultation has taken place.

Please note this form is for repeat prescriptions only, any medical queries can only be dealt with by making an appointment to see a doctor.

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Name *

First

Last

Telephone Number *

Email *

Date of Birth *

Medical Card Number (if applicable)

Select your doctor *Dr. John KilraineDr. Robert HewettDr. Cathal NeugentDr. Colin Mac EoinDr. Adrienne KempleDr. Pamela Lundon

Pharmacy *

Please enter name and address of your preferred pharmacy

Paragraph Text *

For each medication required, enter Medication Name (e.g. Paracetamol), Dosage (e.g. 500mg), Quantity/Dose (e.g 2 tablets/dose), Frequency taken (e.g. 2 times per day)

Supply *

Enter supply needed e.g 1 week, 1 month

Allergies *

List any allergies (if any) or enter 'none'

I consent to and wish to avail of electronic prescriptions which means my prescription can be digitally sent from my GP to my chosen pharmacy. *

• Yes I consent to an electronic prescription

After you submit your request for a private prescription, you will receive an email containing a link for the fee for this prescription. Tick this box to consent to this fee. *

• Yes, I consent to the fee for this private prescription

Submit Prescription Order