Long-term Prescriptions

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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

Please allow 48 hours for prescriptions to be ready and remember to take weekends and bank holidays into account.

* Indicates required field

Name Address Phone number *

Date of Birth *

Nominated Chemist *

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

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

Have you any drug allergies *

THIS FORM IS NOT FOR ACUTE SHORT TERM MEDICATIONS IT IS FOR REGULAR LONG TERM MEDICATIONS

This/These medication(s) are longterm medications *

Yes

PLEASE NOW LIST THE MEDICATION
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

List your medications and doses *

Please allow 48 hours for prescriptions to be ready and remember to take weekends and bank holidays into account.

Submit

Contact Us
133 St Peter's Rd, Walkinstown, D12XN9F
Ph switch 4504168 Fax 4783175

23 Old Bawn Way, Tallaght, D24 TKP0
Ph switch 4504168

Long-term repeat regular prescription request form

PLEASE NOW LIST THE MEDICATIONDO 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
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