Repeat Prescription No Valid Medical Card

REPEAT PRESCRIPTION FORM (No Medical Card)

Patient Name *

Date Of Birth *

Phone Numbers *

Email *

Checkboxes *

I give consent to the above email address being stored in my patient chart and can be used to contact me if the surgery has a query regarding my prescription or for future correspondence.
I DO NOT give consent to KMCGP to use my email address for future correspondence.

(Choose one)

Allergies(if any)

NOMINATED PHARMACY

Pharmacy Name & Address *

Please Note: Once the prescription is complete, the script will be securely emailed to your chosen local pharmacy. You will no longer have to call to the surgery to collect your prescription. Prescriptions are taking 3 working days at present to complete. Please contact your chosen pharmacy regarding collection of medications directly.

MEDICATION

Number of Medications on Form

ATTACH PRESCRIPTIONS

If the medications you are requesting have been prescribed by a hospital, consultant etc, please upload a clear image of the prescription. If you are having problems uploading the image, you can drop a copy of the prescription into our Patient Drop-Box at the surgery door so we can add it to you patient chart.

Prescription Upload (Only if prescribed by hospital, consultant etc.)

Click or drag a file to this area to upload.

PRESCRIPTION PAYMENT

Please Note: There is a €25 fee for this transaction. If a fee is not applicable for your request, an administrator will contact you regarding a refund. NOTE: Payments are handled by Stripe payment gateway, Kildare Medical Centre do not hold card details of customers.

Prescription Cost

Price: 25,00 €

Credit Card Details *

Card

Name on Card

REPEAT PRESCRIPTION FORM (No Medical Card)

NOMINATED PHARMACY

MEDICATION

ATTACH PRESCRIPTIONS

PRESCRIPTION PAYMENT

@2021 Kildare Medical Centre