Long-term Prescriptions

Doctor Visit Card -Threshold now lowered & Under 8’s cards

LONGTERM PRESCRIPTION FORM
THIS FORM IS FOR LONG-TERM PRESCRIPTIONS, YOUR "REGULAR" PRESCRIPTIONS AND NOT FOR ONCE OFF OR SHORT TERM PRESCRIPTIONS, PLEASE DO NOT USE THE FORM FOR ANYTHING OTHER THAN LONG-TERM REPEAT PRESCRIPTIONS

Long-term repeat regular prescription request form

USING THIS FORM FOR ANY OTHER PURPOSE, ASKING QUESTIONS, REQUESTING OTHER SERVICES ETC DISTRACTS FROM THE IMPORTANT PROCESS OF PRESCRIBING LONGTERM MEDICATION
ANY FORMS USED FOR ANY OTHER PURPOSE OTHER THAN REQUESTING LONGTERM MEDICATIONS WILL BE IGNORED
DO NOT REQUEST SHORT TERM ONCE OFF MEDICATION USING THIS FORM

* Indicates required field

NAME ADDRESS PHONENUMBER *

Date of Birth *

Are you a medical card holder? *

Do you have a Longterm Illness Book or Card *

PRIVATE REPEAT LONGTERM PRESCRIPTIONS INCUR A CHARGE OF 20 EURO

When did you last have a consultation with one of our GPs *

Have you any drug allergies *

These are my regular LONGTERM medications prescribed by the GP surgery *

Yes No

If you are filling this on behalf of patient please give your details *

PLEASE NOW LIST THE MEDICATION
TO REDUCE PRESCRIBING ERRORS LIST ALL THE TABLETS DO NOT WRITE "AS BEFORE" OR "LIST ON FILE"
WE NEED YOU TO LIST WHAT YOU ARE TAKING TO MAKE SURE IT MATCHES OUR LIST

NAME OF YOUR CHEMIST *

HAS THE PATIENT HAD ANY HOSPITAL ADMISSIONS OR OUTPATIENT VISITS IN WHICH MEDICATIONS MAY HAVE BEEN STOPPED OR DOSES CHANGED *

YES NO

PRIVATE REPEAT LONGTERM PRESCRIPTIONS INCUR A CHARGE OF 20 EURO

List your medications and doses *

Prescriptions are often now given for 6 months please confirm you have checked with pharmacy that prescription is due *

No Yes

Please allow 72 hours for prescriptions to be ready and remember to take weekends and bank holidays into account.

Submit

Long-term repeat regular prescription request form

PLEASE NOW LIST THE MEDICATIONTO REDUCE PRESCRIBING ERRORS LIST ALL THE TABLETS DO NOT WRITE "AS BEFORE" OR "LIST ON FILE"WE NEED YOU TO LIST WHAT YOU ARE TAKING TO MAKE SURE IT MATCHES OUR LIST

PLEASE NOW LIST THE MEDICATION
TO REDUCE PRESCRIBING ERRORS LIST ALL THE TABLETS DO NOT WRITE "AS BEFORE" OR "LIST ON FILE"
WE NEED YOU TO LIST WHAT YOU ARE TAKING TO MAKE SURE IT MATCHES OUR LIST