Flu Vaccine Request
Repeat Medication Order Form
Indicates required field
Date of Birth
We may need to contact you in relation to prescription request.
Select Your Regular GP
I would like to book a Flu Vaccine and confirm I am (select one from below)
Select one from list here
Aged 65 years or over
Under 65 Years in an At Risk Group
Health Care Worker
Child Aged 2 to 12 Years (available Mid October)
The Flu vaccine provided free for for those in these groups only.
Select Your Preferred Pharmacy. We will arrange for your prescription to be passed to any of the Pharmacies listed belowbelow
Select Your Pharmacy
Lynch's Pharmacy Virginia
McCrystal's Pharmacy Virginia
O'Donoghue'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 provide pharmacy name and fax number in box below
Select your preferred Pharmacy and we will forward your prescription directly to them - please allow 48 hours
List Long Term Medications Required below [Medication name, strength and dosage]
Please list the drug name, strength and how often you take your medication eg. Paracetamol 500mg 2 tablets twice a day
Please allow 48 hours for your Repeat Prescription to be prepared and sent to your choice of Pharmacy. Please note only long term medications can be requsted using this form. Please do nominate a pharmacy and we will notify them directly, if you do wish to collect your prescription, please telephone us before presenting. If you require none long term medication or have a medication query please contact the surgery on 049 8546222 (option 1) as we will be unable to repond to any query using this form. Our lines are extemely busy at present but please do bear with us as we work through these changing times.
Please do not present to the surgery without speaking with us first, this is for your stafety as well as the saftey of our staff. We appreciate your patience and undertanding.
Please Click on
" to forward your request. Many thanks.
Flu Vaccine Request