Repeat Prescription Request - No Charge

This page is only for patients with a Medical Card or Doctor Visit Card, or patients aged 17 – 35 who are requesting contraception.

Medical Card / Doctor Visit Card / PPS Number *

Please enter your Medical Card or a Doctor Visit Card, or your PPS Number if aged 17 - 25 and requesting contraception.

Patient's Name *

Address *

Date of Birth *

Phone Number *

Pharmacy Name *

Your prescription will be sent electronically to your nominated pharmacy. Please ensure that you include the address (town name) of your pharmacy

Medication(s) Requested (one per line) *

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

Additional information / additional medications

Choice of GP *

At Gorey Family Practice, we want to provide patient centred care. We ask patients to book with the same GP, if possible, for each appointment to allow the GP to get to know you and your health needs. Please tell us which GP you prefer to see, or enter 'No Preference' if you don't have any preference.

If your GP of choice is unavailable and you need an appointment urgently we will book you in with an available doctor.

Data Protection *

By using this form you agree with the storage and handling of your data by this website. We value your privacy. You can learn about how we handle information by viewing our privacy policy.

All prescriptions are now issued directly to your nominated pharmacy and we will no longer be issuing paper prescriptions. Please allow 5 working days before contacting your pharmacy to arrange collection/delivery of your requested medication.

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