Repeat Prescription Request - Gorey Family Practice

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 by ticking one box.

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

Repeat Prescription Payment *

I am a private patient and have paid the €25 charge (enter PayPal email address below)
I have a medical card / doctor visit card - no payment needed (enter medical card / doctor visit card number below)
I am aged 17 to 25 and am requesting contraception - no payment needed (enter PPS Number below)

PayPal Email address

Please enter the email address of the PayPal account that paid the €25.

Medical Card / Doctor Visit Card Number

If you have a Medical Card or a Doctor Visit Card, please enter your medical card / doctor visit card number.

PPS Number

If you are 17 - 25 and requesting contraception, please enter your PPS Number.

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 3 working days before contacting your pharmacy to arrange collection/delivery of your requested medication.

Phone

There is a €25 charge for private patients.

If you are a private patient and have not already paid this, please do so now. You can pay by PayPal, credit card or debit card.

You will be brought back to this page after payment.

There is no charge for patients who have a Medical/Doctor Visit (DV) / Under 6 card, or patients aged 17 – 25 who are requesting contraception.