Please note: This page is strictly for ordering repeat prescriptions. Please do not enter any other information or requests on this page.

Please ensure we have up to date details of which pharmacy you wish to use and your prescription will be sent directly to a pharmacist of your choice.

All patients on repeat medications must see a doctor or practice nurse at the surgery at least once a year to review their medications.

We require 3 working days’ notice for all prescription requests.

Please remember to take weekends and public holidays into account.

Repeat Prescription Form

Name

Name of the patient the medication is for:

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone Number

(###)

###

####

Your Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

GMS Number

Medical Card / GP Card Number if applicable:

Pharmacy

We will send the prescription electronically to your nominated Pharmacy:

Prescription Required

I confirm I have received this medication (or these medications) from Coolock Family Practice in past 12 months and I confirm this request does not include a request for an antibiotic:

Yes I confirm

Repeat Prescriptions

Please note: This page is strictly for ordering repeat prescriptions. Please do not enter any other information or requests on this page.

Repeat Prescription Form