Repeat Prescription Request - Gorey Family Practice

There is a €20 charge for private patients. If you are a private patient and have not already paid this, please do so now via PayPal *

You will be brought back to this page after payment.

* Please note : using this option, you can simply pay by credit card – you do not need to have a PayPal account.

Repeat Prescription Payment *

I have a medical card - no payment needed
I am a private patient and have paid the €20 charge

Name *

Address *

Date of Birth *

Phone Number *

Pharmacy Name

We can arrange for your prescription to be sent to a pharmacy in Gorey town, otherwise your prescription must be collected from the surgery in Gorey Shopping Centre.

Medication(s) Requested (one per line) *

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

PLEASE TICK TO GIVE CONSENT FOR SOMEONE ELSE TO COLLECT YOUR PRESCRIPTION

Due to data protection legislation, you must collect your own prescription. If you are unable to collect it, you can ask your pharmacist to collect it. Alternatively you can arrange for another person to collect your prescription, by filling in the name below.

Nominated person's name

I nominate the person named here to collect my prescription from Gorey Family Practice as my pharmacy is outside Gorey Town. I understand that whoever collects the prescription will need to bring photo ID with them each time.