Private Repeat Prescription Request

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Name *

First

Last

Email *

Phone No. *

Home address *

Select your Doctor *

Nominated Pharmacy *

Where will we send your prescription?

Medications (include name of medication, dose, duration) *

Eg. Ibuprofen, 200mg, 2 tablets/dose, 3 times daily, 1 month

Allergies

Leave blank if not applicable

Checkboxes *

I consent to my prescription being sent digitally from the practice to my chosen pharmacy.

Checkboxes *

I acknowledge that it takes up to 48 hours (excluding weekends) to process repeat prescription requests.

Checkboxes *

I understand that I will receive a €20 payment request from the practice via Billink that must be paid before my prescription will be processed.