Date of Birth
GMS Number (if applicable) (a €15 fee applies to patients ordering private scripts)
Preferred pharmacy for us to send your prescription directly to:
Enter drug name, strength and dosage separated by a comma. Please use a separate line for each drug.
Your reorder will be defaulted to 6 months, however actual months given will be at the clinician's discretion.
Please tick as appropriate:
I will collect after 48 hour period has elapsed.
I consent for family member to collect.
A €15 fee applies to patients ordering private scripts.