Order Prescription
Slattery's Pharmacy

First Name *

Last Name *

Date of Birth *

Email Address *

Phone *

Address *

Eircode

County of Residence * Please, select Carlow Cavan Clare Cork Donegal Dublin Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Longford Louth Mayo Meath Monaghan Offaly Roscommon Sligo Tipperary Waterford Westmeath Wexford Wicklow

Your GP's name and contact details *

Delivery Full Address *

Doctor Visit card / DPS Num / Medical card Num *

Do we have your prescription on file? *

Is this a new or repeat prescription? * New Repeat

Dispense all medicines on your prescription? *

If no, which medicines do you need?

Anything else we need to know about your prescription order?

Do you need any other products with your prescription?

Upload a scan or photo of your prescription: *

Formats accepted: jpeg,jpg,bmp,png,pdf,doc,docx,rtf,odt

Do you have an active medical card?

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