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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

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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 An 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.

GP Consultation

GP Consultation 2

Phone Consultation

Flu vaccine for age 2-17y only

COVID + Flu vaccines age 60 and older only

Injectable Flu vaccine for Eligible Patients only

Private Flu Vaccine

Forms/Certificates request

Pre approved blood test

Prescription Request

Free Contraception (Prescription only)

Test results review only

Test results review appointment

Ante-natal follow up visits

Childhood vaccines

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

Long Term Reversible Contraception

Written External/Consultant Blood test request

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