Repeat Prescription Form

This service is for repeat prescriptions requests ONLY.

You can also download our Repeat Prescription Form, print it out, complete it and return it to us either by email, by post or drop it in to us.

Full Name of Patient requiring prescription

Date of Birth

Date of Birth: Day

Date of Birth: Month

Date of Birth: Year

Your Doctor

Note: another doctor may prescribe your medication

Telephone number

Email address

Does the Patient have a Medical Card or Doctor Visit Card?

No (€25 charge)

Yes (Free)

GMS Number

Does the Patient Have any Allergies?

Yes

Please give details of any allergies

I would like you to

Collect my medication from my preferred Pharmacy

Collect my signed prescription from the clinic

Name and address of your preferred pharmacy

Medications

Medication Name	Dosage	Supply	Operations
Medication Name	Dosage	Supply

Please check with your nominated pharmacy that they have received your prescription before you call us to check if we sent it.