Repeat Prescription – Athenry Surgery

Use this online form to order your repeat prescription
This form should not be used for any other service
Allow 48 hours for us to review and process your prescription request, e.g order before 4pm today to collect after 4pm the day after tomorrow
Keep in mind when placing your order that our admin hours are from 9am to 5pm Monday to Friday
State the name of each drug on your repeat list and add the strength and dosage for each one

Ensure to complete all boxes on this form before clicking “Send”.

First Name *

Last Name *

Date of Birth (DD/MM/YYYY) *

Email *

GMS Number (if applicable) (a €20 fee applies for private scripts)

Preferred pharmacy for us to send your prescription directly to:

Enter drug name, strength and dosage separated by a comma. Use a different box for each drug.

Drug 1 *

Drug 2

Drug 3

Drug 4

Drug 5

Drug 6

Drug 7

Drug 8

Drug 9

Drug 10

Drug 11

Drug 12

Drug 13

Drug 14

Drug 15

Your reorder will be defaulted to 6 months, however actual months given will be at the clinician's discretion.

Other Request

Please tick as appropriate:

I will collect after 48 hour period has elapsed.

I consent for family member to collect.

A €20 fee applies to patients ordering private scripts.

Thank you for your order. If applicable, you will be sent a text message from our admin team shortly with a link to pay. Upon receipt of payment your prescription will be processed. Allow 48 hours for it to be sent to your selected pharmacy.

There was an error trying to send your order. Please try again later.