Prescription Request Form

Please allow 5 working days for your prescription request to be completed. Your prescription will be sent directly to your pharmacy of choice. You can can contact your pharmacy after 5 working days to collect your prescription.

Please do not leave a paper copy of your repeat prescription request in the box at the surgery if you have already requested your prescription online.

Payment - Secure link

We have a new secure online payment system that we will be using from now on. Once you request your repeat prescription a secure link will be sent to your phone if a fee is required. This link will contain your invoice for your script. When you click on the link you will be directed to an invoice page where you can make the payment. Once the payment has been processed our admin team will be notified and your script will be authorized by your GP.

To prevent delays in this process - please use secure link once received. Most prescriptions are issued following a consultation with the Doctor. Repeat prescriptions of medication may require a check up with the doctor or nurse. You also may require blood tests to be performed. This is to ensure safe prescribing and is in accordance with evidence based practice Repeat prescriptions for antibiotics are not available

Private Prescription - €25.00

Name

First Name

Last Name

Date of Birth

Mobile number

Address

Eircode

Are you medical card holder?

If you do not hold a medical card or DVC card a charge will apply of €25. You can make a payment by going to the payment section of our website or member of staff will be in contact to arrange payment before your script is prepared (Call will come though as an unknown/private number)

Yes

PPS Number (if non-medical card/Doctor Visit card)

Name of the GP you most regularly attend

What medication do you require?

Please list medication

Which Pharmacy do you go to?

Secure payment

I understand that payment will need to be made via the secure link sent to my phone. If payment is not made within one week the script will be confidentially shredded

I understand

Prescription Request Form

Payment - Secure link

Location

Hours

Contact