Repeat Prescriptions

To request the renewal of a medication that has been previously prescribed by one of our doctors at the clinic,
and as long as it is not a psychiatric / psychological medication.

Full Name

Date of Birth

Phone

Select Your Doctor

Home Address

Name and address of your preferred pharmacy

Consent

I consent to and wish to avail of electronic prescriptions which means my prescription can be digitally sent from my GP to my chosen pharmacy.

Allergies (if any)

Medication

Medication Name

Doseage

Quantity / Dose

Freq. Taken / Day

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