Re-Order Prescription

Please allow 48-72hrs for prescription refill to be ready. Note this form is for re-orders only.

First Name *

Last Name *

Date of Birth *

Phone Number *

We will contact you at this number

Email Address

We will send you a copy of this form for your records

Do you need a refill of a contraceptive pill? *This field is required. Please select a value.Please note, refills of contraceptive pill are not charged under the Free Contraception Scheme.

Do you require other medication? *This field is required. Please select a value.You will be charged for refill of other medications.

Do you have a medical card? *This field is required. Please select a value.Please note if you are not a medical holder and you select “yes”, this order will be invalid and your prescription will NOT be processed.

Medical Card Number

Drug 1 *