Repeat Prescriptions

A form to apply for a repeat prescription

Name
First Last
Address*
Street Address Address Line 2 City County
Phone*
Email
Date of Birth*
DD slash MM slash YYYY
Prescription*
DRUG NAME DOSE TIMES/DAY
Pharmacy*
Please select a pharmacy from the dropdown menu to which your prescription should be sent.
Please enter Other Pharmacy address
Prescription Fee - choose Private or GMS*
Medical Card Number*

If you do not know your medical card number please call the HSE Medical Card information number on 1890 252 919
Credit/Debit Card
Card Details
Cardholder Name

DRUG NAME	DOSE	TIMES/DAY