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Repeat Prescription Form

Name *

Surname *

Date of Birth *

E-Mail address*

Contact Number*

Select Your Doctor*

Do you have medical or doctor visit card ?*

Yes

Medical/ doctor visit card Number *

Repeat Prescription

Name and Address of Your Preferred Pharmacy *

Allergies (if any) *

MEDICATION*

Regular/New	Medication Name	Strength	No.of Tabs/Time	Freq. taken/Day	Duration

Upload Document (Optional)

Which is bigger, 3 or 6 ? *

your answer is incorrect!

I consent to and wish to avail of electronic prescriptions which means my prescription can be digitally sent from my GP to my chosen pharmacy.

It may take up to 3 to 5 days to process your request.