Repeat Prescription No Valid Medical Card

REPEAT PRESCRIPTION FORM (No Medical Card)

Patient Name *

Date Of Birth *

Phone Numbers *

Email *

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.

Prescription Cost

Price: 25,00 €

Credit Card Details *

Card

Name on Card