Prescription request

Repeat medication request form

Below is a form to request a repeat prescription for your regular medication. Please note that this is only for medication that you are already on. If you need a prescription for a new medication or something that we have not prescribed for you in a long time you will need a consultation with a doctor.
Please remember to put the medication name (rather than what you take if for) and dose (“strength”).
Use one line per one medication.
You will receive an e-mail with confirmation of what you have requested.
Please allow at least 48 hours for your request to be processed.
Your prescription will be emailed to the pharmacy you have indicated below and you should contact this pharmacy to arrange collection of your medication.
For private patients (patients with no medical or doctor visit card) you can pay the fee for your prescription securely on this website.

First Name

Last Name

Date of Birth

Phone/Mobile

Do you have medical or doctor visit card?

Yes

This is for contraception only and I am aged 17-26

Do you need receipt now?

Yes (you will receive it by e-mail)

No (you will call at end of year for summary)

Repeat prescription

Fee: €20.00

Pay with Card (Stripe)

Medical / doctor visit card number

Your Pharmacy

Other chemist

Medication required

I have read and agree to the Privacy Policy

I understand it might take up to 48h for request processing