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 for each one. Select amount of months required at the end.
Select the number of months supply required:
One monthTwo monthsThree months
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.