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Repeat Prescriptions

You must be a current patient of HearMed Medical Centre to request a repeat prescription.
This facility is for prescription requests only.
Please allow 48 hours for your prescription request to be processed. A repeat prescription fee of €25 is applicable. A link will be sent to you by text message with a secure payment link.

Step 1/2:

Leave this field blank

Repeat Prescription Form

Please complete this form in English only

Your Name

Mobile Number

Home Number (optional)

Your Email

Date Of Birth

*For mobile devices, tap the year on top left of popup calendar to select DOB year

Do you Have Any Allergies?

Yes

Please State Your Allergies Here

I Would Like To...

Collect my medication from my preferred Pharmacy

Collect my signed prescription from the clinic

Name and address of your preferred pharmacy

Please check with your nominated pharmacy that they have received your prescription before you call us to check if we sent it.

Medications

Medication Name

Dosage

Supply

2. Do You Want To Add Another Medication?

Yes

Medication Name

Dosage

Supply

3. Do You Want To Add Another Medication?

Yes

Medication Name

Dosage

Supply

4. Do You Want To Add Another Medication?

Yes

Medication Name

Dosage

Supply

5. Do You Want To Add Another Medication?

Yes

Medication Name

Dosage

Supply

6. Do You Want To Add Another Medication?

Yes

Medication Name

Dosage

Supply

I agree to the storage and handling of my data by HearMed Medical Centre

I agree

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