• Main Street, Ballincollig, Co. Cork, P31 DA59

Online Payment*

Prescription Fee for Private Patients – €20

*Required. If you are a private patient, you will need to pay €20 when ordering your prescription.  

Before filling the information below, you can pay the fee safely and securely using the form here.

Once payment is made, fill the form below and click SEND.

**Non-payment will delay the processing of your request.**

Payment details


Please note:

    Your Details:

    Do you have a medical card?

    Pharmacy Details:

    Medication Details:

    e.g.: Panadol


    3 times daily

    2 tabs

    1 month

    Please Note:

    • Please allow 48 hours for request to be processed.

    • Patients may be asked to attend Dr for review depending on last attendance and current medications requiring monitoring.

    GDPR: We will only use the information you provide us in this form to deal specifically with your request for a repeat prescription and we will not use it for any other purpose.

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