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Birth Assigned Sex*

Name*

Surname*

Date Of Birth*

Phone No.*

Email*

PPS No.*

Brief reason/s for the request*

Eir-Code*

CSID*

Your appointment with :

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)

Do you have medical or doctor visit card ?*

Yes

Medical/ doctor visit card Number*

I declare that the requested appointment is non urgent and if there is a change in my situation I will notify the practice immediately or contact 999/112 as appropriate

Book Appointment

Please note that if you are not a registered patient of Agarwal Wellness and Medical Centre, neither an appointment nor a refund for the booked services is guaranteed. We appreciate your co-operation. Thank you.

Long Term Reversible Contraception

€ 175.00

Phone Consultation

€ 80.00

Ante-natal follow up visits

€ 0.00

Test results review only

€ 40.00

Forms/Certificates request

€ 30.00

Pre approved blood test

€ 40.00

Free Contraception (Prescription only)

€ 0.00

Expression of interest for Cervical Screening ('Pa...

€ 0.00

Childhood vaccines

€ 0.00

Prescription Request

€ 30.00

GP Consultation 2

€ 80.00

GP Consultation

€ 80.00

Written External/Consultant Blood test request

€ 60.00

Test results review appointment

€ 40.00

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