New Patient Registration
REQUEST FOR REPEAT FREE CONTRACEPTION PRESCRIPTION
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Indicates required field
Name
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First
Last
Date of Birth
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PPS Number - Required by the HSE
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Phone Number
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Address:
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I confirm
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I am Aged from 17 to 35 years
I have had a Pill Check Appointment in the last 12 months
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Yes
No - Please note message at end of Request Form
If you have not had a contraception review appointment in the last 12 months, you must make an appointment within 3 months to join the free scheme
Repeat Contraceptive Item Required;
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Enter Drug Name in box below
Enter Nominated Pharmacy if Not List above
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Nominated Pharmacy
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Select from list below
Lynch's Pharmacy, Virginia
McCrystal's Pharmacy, Virginia
O'Donohgue's Pharmacy, Virginia
Gormley's Pharmacy Ballyjamesduff
Green's Pharmacy Ballyjamesduff
Lynch's Pharmacy, Oldcastle
McQuaid's Pharmacy, Oldcastle
McNally's Pharmacy, Mullagh
Cara Pharmacy, Bailieborough
Jameson's Pharmacy, Bailieborough
Other please nominate in box below
IMPORTANT - If you have not had a Contraceptive Check Up in the last 12 months, please make an appointment for your "Free Contraception Consultation" within 3 months. The Free Consultation covers Contraceptive Services only.
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Submit
New Patient Registration
