ORDER PRESCRIPTION

Are you a registered patient with us? (Must be a paitent to order)

First name:

Last Name:

Email ADdress:

Date Of Birth:

Phone Number:

Name of your pharmacy (prescriptions will be sent directly):

Have you attended or spoken with a doctor in the past 6 months?

Repeat Medications: * Name, dose, frequency. E.g. Bisoprolol, 2.5mg, once da...

Suirside Medical Centre,

The Gables, Old Waterford Road, Clonmel,

Co. Tipperary.

E91 H0X2

Ireland

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