Repeat Prescription – Kildare Medical Centre

REPEAT PRESCRIPTION FORM

Name *

Date Of Birth *

Phone Numbers *

Email *

Medical Card Number(If Applicable)

Allergies(if any)

NOMINATED PHARMACY

Pharmacy Name & Address *

Please Note: Once the prescription is complete, the script will be securely emailed to your chosen local pharmacy. You will no longer have to call to the surgery to collect your prescription. Prescriptions are taking 3 working days at present to complete. Please contact your chosen pharmacy regarding collection of medications directly. There is a €25 fee for each private patient prescription. Please call the surgery to arrange payment.

MEDICATION

Number of Medications on Form