Order Prescription

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Please tick either the box relevant to you/your order*

Private prescription

Medical Card/Doctor Visit Card Holder

Contraception – For those aged 17 to 35 no fees apply. (Covered up until the day before your 36th birthday)

Garda Medical Aid

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City County / State / Region EIRCODE

Phone Number*

Name of Doctor*

Name of Pharmacy*

Pharmacy's Address*

List medication required for repeat issue. Please include dosage. Please note : failure to state medication names may result in delays in processing.*

Please note it takes 48 hours (working days) to process your repeat prescription. Your prescription will be in your chosen chemist in 48 hrs (working day) unless you hear from us otherwise.

Repeat*

Once off

1 month

3 months

6 months