Online Forms to Get Your Answers Quicker

Request a Repeat Prescription

We accept prescription requests by written request only. We aim to have all prescription requests reviewed within 2 working days. Prescriptions will be emailed directly to your nominated pharmacy.

For Private patients, a €20 charge for prescriptions applies. Please proceed to payment and you will be asked to complete the prescription form at checkout.

Please note, if your prescription is unchanged from previous one there is no need to complete each item on the form below. Only list any new or changed items from previous prescription.

Repeat prescriptions will only be issued if they are not due for review by a doctor.

Repeat Prescription, for Private Patients

€20.00

Quantity:

Pay Now

Repeat Prescription for GMS Patients

Name

First Name

Last Name

Repeat Prescription Request

Date of Birth

YYYY

PPS Number

Item 1 Name

If your prescription is unchanged from previous one there is no need to complete each item below. Only list the items if there are some that are not needed or changed from previous prescription.

Item 1 Dose

Item 1 Quantity

Item 2 Name

Item 2 Dose

Item 2 Quantity

Item 3 Name

Item 3 Dose

Item 3 Quantity

Item 4 Name

Item 4 Dose

Item 4 Quantity

Item 5 Name

Item 5 Dose

Item 5 Quantity

Item 6 Name

Item 6 Dose

Item 6 Quantity

Item 7 Name

Item 7 Dose

Item 7 Quantity

Name of Pharmacy you would like the prescription sent to

Covid-19 Screening Form

If you suspect that you might have COVID-19, are displaying symptoms, or a close contact of a confirmed case, please complete this screening form before calling the surgery.

If you have difficulty breathing and feel it is a medical emergency, please phone 999 or 112

This form is for use during working hours Monday to Friday only.

Submitting forms outside this time will delay your test referral.

Outside these times please phone MIDOC on 1850 302 702 who will refer you for testing. If you submit a form over the weekend it will not be seen until Monday morning.

Ensure that you have the correct phone number. When you click ‘submit’ a secure email will be generated and a doctor will review the information and decide on the best course of action for you. Until you hear from us, please start self-isolating. One of our doctors/nurses will either call you to discuss or may decide to make a referral directly for testing. If this is the case, you will receive a text message from the HSE advising of the time and location for a test.

* Items marked with a star are mandatory, we must have a contact number so we can phone you if we are unsure of what you require.

COVID Screening Questionnaire

Name

First Name

Last Name

Phone Number

Date Of Birth

YYYY

Eircode

PPSN

SYMPTOM CHECKER

PLEASE SELECT YES OR NO FOR THE FOLLOWING SYMPTOMS

Fever/Chills (fever usually above 38 degrees)

Cough (can be dry or productive)

Difficulty breathing/shortness of breath

Change to or loss of taste or smell

Sore Throat

Runny Nose

Diarrhoea

Vomiting

Aches & Pains

Fatigue

No Symptoms

If you have no symptoms you are unlikely to currently meet the criteria for testing

Are you or could you be pregnant

DURATION OF SYMPTOMS

When did you start displaying symptoms?

HAVE YOU HISTORY OF RECENT TRAVEL?

If YES, to where did you travel

ARE YOU CURRENTLY SELF-ISOLATING?

ANYBODY WITH RESPIRATORY SYMPTOMS OF ANY KIND IS ADVISED TO SELF-ISOLATE.

HAVE YOU HISTORY OF CONTACT WITH A CONFIRMED CASE OF COVID-19

Brief outline of your symptoms/concerns:

Give a brief outline of your symptoms when they started and your concern for testing, If you have any other symptoms not covered in the checklist above, please let us know

Pre-Existing Medical Conditions?

Please outline any significant pre-existing medical conditions that may put you in an at-risk category.

Register for a COVID Vaccine

Reminder – Please register on the HSE portal for a vaccine as soon as it opens for your age group. Register to get a COVID-19 vaccine (hse.ie)

Blood and Other Test Results Form

Please note, if your doctor has advised you to make an appointment to come back to them once your results are back, please do not complete this form. Please contact reception for an appointment.
Submitting this form will generate an email to one of our nurses who will review your file and contact you once all your results are back.

Bloods and other test results form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth

YYYY

PPSN

Phone Number

If you require a phone call with results / copy of results please tick below. We will deal with requests as soon as possible.

I would like someone to contact me with my results

I would like a copy of my results for hospital/consultant

Baby Vaccination Form

If you need to get your baby added to your medical card, please let us know before your baby is 6 months old.
If you do not have a medical card, your baby is entitled to a GP Visit card. Please visit www.gpvisitcard.ie to register your baby as soon as possible after birth. You do not need to wait for your baby's PPSN to do this.

When you click submit you are agreeing to us holding your information in accordance with GDPR and are giving consent for us to contact you by email or by text. One of our nurses will be in contact with you to arrange an appointment.

Baby Vaccination form

Your Name

First Name

Last Name

Your Baby's Name

First Name

Last Name

Subject

Message

Baby's Date Of Birth

YYYY

Phone Number

Vaccinations requested

If other please specify below

Any other relevant information you think we should know:

Any other queries you have?

Medical Cert Request Form

*** Please note medical certificates will not be issued unless you have seen the doctor ***

Request a Medical Cert

Name

First Name

Last Name

Date Of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

What illness goes on your certificates?

What type of cert do you require?

IF YOU NEED BOTH PLEASE TICK BOTH BOXES

Private Work Certificate

Social Welfare Certificate

What date is your cert due from?

YYYY

For how long so you require cert?

All Certs will be posted or can be emailed, please state your preference. There is a charge for private certs. Please go to our payments section to make payment as certs will not be issued until payment has been received. There is no charge for social welfare certs. These will be submitted electronically to the Department of Social Welfare and a copy will be retained on your file.

ONCE YOU CLICK SUBMIT IT WILL GENERATE AN EMAIL FORM TO US. WE WILL DEAL WITH IT AS SOON AS WE CAN. When you click submit you are agreeing to us holding your information in accordance with GDPR and are giving consent for us to contact you by email or by text.

Online Forms to Get Your Answers Quicker

Request a Repeat Prescription

Covid-19 Screening Form

Register for a COVID Vaccine

Blood and Other Test Results Form

Baby Vaccination Form

Medical Cert Request Form

Travel Vaccine Questionnaire

Kilbeggan Medical Centre