Prescription Request Form For Private Patients

SKU:

€20.00

Unavailable

per item

This is for private clients only, thank you.

Full Name *

Email *

Telephone/Mobile Number *

Date of birth? *

Choose Your Doctor Select all that apply Dr. Bridgit Halley Dr. Gerard Barrett Dr. Diarmuid Gannon Dr. Sinead Cooney Dr. Paddy Davern Dr. Cliodhna O’ Callaghan

Name Of Your Pharmacy *

Address Of Your Pharmacy *

Are You A: Select all that apply Private Patient - YES

Medication - Please type your medication including dosage, number of tablets/doses per month and frequency here. One line for each medication.

By using this form you agree with the storage and handling of your data by this website. Select all that apply Yes

Quantity

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Location

Cashel Medical Centre, Feehan's Rd, Cashel, Co. Tipperary, E25 RD21

Contact Us

062 61 715

Monday 09:00 – 12.30 & 14:00 - 17:00
Tuesday 09:00 - 12:30 & 14:00 - 17:00
Wednesday 09:00 - 12:30 & 14:00 - 17:00
Thursday 09:00 – 12.30 & 14:00 - 17:00
Friday 09:00 – 12.30 &14:00 - 17:00
Emergencies only 5-6pm

CAREDOC 0818 300 365