Prescription Order Form

Patient Details

Full Name (* Mandatory Field)

Date of Birth (*)

Your Email (*)

Daytime Tel (*)

Your GP (*)

Your Pharmacy (*)

During the current Covid 19 crisis, where possible we will deliver your prescription to your nominated pharmacy. Please ensure these details are provided above. Please allow a minimum of 48 hours for delivery to the pharmacy. Please note prescriptions ordered on a Friday will only be available from the following Monday.

Medication

To provide us with your prescription details you can download our form and upload it to here or alternatively fill out the details below.

Click here to download our form. To upload you prescription order, add your file here

You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time.

Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending.

	Drug	Quantity and/or Strength e.g. 1mg once a day	Required
1.			required
2.			required
3.			required
4.			required
5.			required
6.			required
7.			required
8.			required
9.			required
10.			required
11.			required
12.			required
13.			required
14.			required
15.			required
16.			required
17.			required
18.			required
19.			required
20.			required

Comments

Please do not include medical problems here - these should be discussed with your doctor

Livinghealth Clinic, Fermoy Road, Mitchelstown, Co. Cork.

Monday – Friday 8.00am to 5.30pm
Saturdays, Sundays & Bank Holidays – Closed

Monday – Friday 9.00am to 5.00pm
Saturdays, Sundays & Bank Holidays – Closed