Please Select if you are Medical card Patient or Private Patient. Medical Card Private Your name Address Please select one of the following options: I will call to collect my PrescriptionPlease post my Prescription (SAE Required)My Pharmacy will collect my Prescription Please Select Pharmacy:Bourke's RathminesLloydsBurkes RanelaghDunville PharmacyLeech PharmacyOther If other please state name and address of the Pharmacy: 1.Drug Name: Duration of Drug 1: One MonthThree MonthsSix Months 2.Drug Name: Duration of Drug 2: One MonthThree MonthsSix Months 3.Drug Name: Duration of Drug 3: One MonthThree MonthsSix Months 4.Drug Name: Duration of Drug 4: One MonthThree MonthsSix Months 5.Drug Name: Duration of Drug 5: One MonthThree MonthsSix Months 6.Drug Name: Duration of Drug 6: One MonthThree MonthsSix Months 7.Drug Name: Duration of Drug 7: One MonthThree MonthsSix Months 8.Drug Name: Duration of Drug 8: One MonthThree MonthsSix Months 9.Drug Name: Duration of Drug 9: One MonthThree MonthsSix Months 10.Drug Name: Duration of Drug 10: One MonthThree MonthsSix Months Comment Choose payment Pay with Stripe Your name Address Please select one of the following options: I will call to collect my PrescriptionPlease post my Prescription (SAE Required)My Pharmacy will collect my Prescription Please Select Pharmacy:Bourke's RathminesLloydsBurkes RanelaghDunville PharmacyLeech PharmacyOther If other please state name and address of the Pharmacy: 1.Drug Name: Duration of Drug 1: One MonthThree MonthsSix Months 2.Drug Name: Duration of Drug 2: One MonthThree MonthsSix Months 3.Drug Name: Duration of Drug 3: One MonthThree MonthsSix Months 4.Drug Name: Duration of Drug 4: One MonthThree MonthsSix Months 5.Drug Name: Duration of Drug 5: One MonthThree MonthsSix Months 6.Drug Name: Duration of Drug 6: One MonthThree MonthsSix Months 7.Drug Name: Duration of Drug 7: One MonthThree MonthsSix Months 8.Drug Name: Duration of Drug 8: One MonthThree MonthsSix Months 9.Drug Name: Duration of Drug 9: One MonthThree MonthsSix Months 10.Drug Name: Duration of Drug 10: One MonthThree MonthsSix Months Comment
