We’re excited to share our new Online Booking app!This new system allows you to book appointments and order your prescription online. To get started, click here

You can still use the form below if you do not wish to use the new online system

"*" indicates required fields

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

Are you a registered patient with us?*

Yes

No

Unfortunately, we cannot process your request as you are not registered with us. Please contact your own GP.

Name*

Date of Birth*

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MonthMonth123456789101112

YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Address*

Street Address Address Line 2 Town/City County Eircode

Contact Number*

Medical Card or Private?*

Medical Card

Private

Medication required*

Repeat Prescription:*

Repeat 1 month

Repeat 3 months

Repeat 6 months

Have you attended/spoke to a doctor in the last 6 months for a medication review?*

Yes

No

Script may not be issued without a medication review.

Name of nominated pharmacy*

Additional information

Prescription Fee

Price:

Total

Credit or Debit Card*

Card Details

Cardholder Name

Privacy Policy*

We will use your data above to process your prescription. We will not use your data for any other purpose.

I consent to you collecting my details

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