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Prescription Renewal Form

North Gate Medical Centre operates a policy of accepting repeat prescription requests in written form only.

This policy is in place to:

  • Ensure maximum patient safety.
  • Ensure that patients are aware of the medications they are requesting.
  • Reduce the risk of prescribing of unnecessary medications.
  • Ensure accurate records of patient medication requests are retained.
  • Minimise human error.
  • Repeat prescriptions will only be issued within 5 days of being due and therefore we do ask that you only order your prescription within 7 days of being due.

We aim to have all prescription requests reviewed within 3 working days. Please do not attend surgery to collect your prescription prior to this period.

Prescription Request Forms can be delivered to North Gate Medical Centre by the following means:

1) On-line – Please fill in website on-line form

2) Hand delivered – Please download the Prescription Request form at www.northgatemedicalcentre.ie and place in request box at reception

We kindly ask that all prescription renewal requests be made using this form

1 Person2 People

Fields marked with a asterix(*) are compulsary

Where you can be reached if GP has a question

Fields marked with a asterix(*) are compulsary

Where you can be reached if GP has a question

Medication * Dose * Quantity taken each dose * Number of times taken * Is this item due
on repeat within the next
7 days? *
e.g. Panadol 500mg 1 tab 2 times daily NO(from dropdown)


North Gate Prescription Renewal Form

Fields marked with a red asterix are compulsory

This form uses cookies to store your information for next time.

The information is stored on your computer when you send your request or when you switch patients - but only if you check the ‘Remember my details...’box

To save details for a second person use the radio button at the top of the form. To save details for more than two people or if you are having trouble with cookies, register with the prescription service and your details will be saved securely in the online database and recalled with you log in. Registering is quick, simple and free.

Personal Information

By using this form you will be sending information about yourself across the internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of ordering a repeat prescription.