Prescription Request - Blackrock Medical Centre, Cork

1. A minimum of 48 hours' notice is required for repeat prescription requests. *

I Agree

2. All medications must be reviewed at least every 6 months by your GP. If you have not had such a review, you may be given a 1 month prescription now and you will have to schedule a GP consultation for review. You will be informed if this situation applies to you. *

I Agree

3. Prescriptions are now sent electronically directly to pharmacies. You must input the pharmacy you wish us to send your prescription to. *

I Agree

4. If you do not hold a current Medical Card, a fee will apply for this prescription and you will prompted to make payment as part of this online request. *

I Agree

5. By using this e-prescription request form, you are sending information about yourself across the Internet. Secure links to ensure the safe and strictly private transmission of your details have been built into this system but it is impossible to guarantee absolute privacy. Your prescription request will be recorded on your secure patient file and this e-form containing your data will then be destroyed. You proceed with this request by consent and agreement to the storage and handling of your data in this way. *

I Agree

I confirm I have read and understand the above conditions and hereby authorise Blackrock Medical Centre to process my request. *

I Agree

Patient Details

Name *

First

Last

Date of Birth *

PPSN Number *

Phone *

Email *

Eircode *

Prescription Details

Pharmacy Name *

Pharmacy Address *

List Medications Required

Medication 1 *

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

Medical Card Holder or Private Patient *

Medical Card Holder
Private Patient

No of Months (Medical Card) *

No of Months (Private Patient) *

Bank Card Details *

Card

Name on Card

Total

€0.00

GDPR Agreement *

I consent to my details being held by Blackrock Medical Centre. No card details are stored.