Your Details

Your First Name *

Your Last Name *

Your Phone Number *

Your Email *

Your Address

Address Line 1

Address Line 2 (optional)

City

county

Eircode

Patient details

Is the patient a private patient ? *

Yes

No

Patient’s Medical card number or Doctor visit card number

Is the patient aged 17 to 26 and requesting a prescription for contraception?

Yes

No

A charge of €20 will be sent by text for any other medications requested.

Patient’s First Name *

Patient’s Last Name *

Patient’s Date of Birth *

Patient’s Address

Patient's Address

Address Line 1

Address Line 2 (optional)

City

county

Eircode

Prescription details

Please advise which prescriptions you would like to order allowing one line per item.
If you want to add prescriptions for a second patient, please select second patient below.

Which Prescription do you want to order? *

Pharmacy

Select the pharmacy you want to collect your prescription from * Select the pharmacy you want to collect your prescription from

Wallace’s Pharmacy,
Ballyvolane Shopping Centre,
Ballyvolane, Cork

Carrignavar Pharmacy
Unit 3&4
Main St Carrignavar
Co. Cork

Blackpool Late Night Pharmacy,
34 Watercourse Rd, Blackpool,
Cork, T23 PRH6

Glenheights Pharmacy,
4 College Shopping Centre,
Ballyvolane, Cork

Sam McCauley’s Blackpool,
Unit 15/ 17,
Blackpool Shopping Centre, Cork

Boots Blackpool,
Blackpool Retail Park,
Blackpool, Cork

Bourkes Pharmacy,
4A Iona Park,
Mayfield, Cork

Irwins Pharmacy,
Unit 1, Mayfield Shopping Centre,
Mayfield, Cork

Phelan’s Pharmacy,
Crestfield Centre,
Glanmire, Co Cork

Pharmacy First Plus Glanmire,
Hazelwood Rd, Riverstown,
Glanmire, Co. Cork

Owenacurra Pharmacy,
79 Main St, Midleton,
Co. Cork, P25 PY99

McElligott’s Pharmacy Blarney,
Ashdale House, Shean Lower,
Blarney, Co. Cork

Hickey’s Pharmacy Mayfield,
Murray’s Supervalu,
Old Youghal Rd, Mayfield, Cork

Pharmacy First Plus Northside,
Glenwood Drive Cork

Payment

Fee for the prescription is €20.
Payment will be taken through Stripe. You do not need a Stripe account.
You will receive an email confirming your payment.
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Your Details

Patient details

Prescription details

Pharmacy

Payment