SCROLL TO THE VERY BOTTOM OF PAGE FOR COVID SCREENING FORM

BELOW YOU WILL FIND REQUEST FORMS FOR

PRESCRIPTIONS, BLOOD TESTS, GENERAL MEDICAL ENQUIRIES, BABY VACCINATIONS, MEDICAL CERTIFICATES, ANTENATAL SERVICES & COVID-19 SCREENING FORM

For enquiries not covered by the forms below, please call us on (057) 9151247.

PHLEBOTOMY / BLOOD TEST RESULTS REQUEST FORM

Name

First Name

Last Name

ADDRESS

PLEASE INCLUDE EIRCODE IF KNOWN

Date of Birth

PPSN

Phone

(###)

###

####

If your blood test is required for hospital/consultant visit

Please specify which consultant, approximately when your appointment is and what blood tests are required. If same as previous blood tests required, write same as previous

If blood test is routine or follow up please specify what blood tests you are looking for:

If blood test is for diabetic check up/heartwatch do you need to be fasting?

Yes

Are you looking for results of tests already taken?

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

Yes, I would like someone to contact me with my results

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

No, I am requesting a blood test appointment now

When you click submit your form will be sent to us by email and we will contact you to let you know when there is a clinic taking place. We will prioritise appointments depending on need / urgency so it may be a few days before you hear from us. 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.

GENERAL MEDICAL PROBLEMS/OTHER ENQUIRIES

Name

First Name

Last Name

DATE OF BIRTH

Address

EIRCODE

Phone

(###)

###

####

PPSN

Subject

Message (It is very helpful for prioritising calls/appointments if you can briefly let us know what your query is about))

WHEN YOU CLICK SUBMIT, AN EMAIL WILL BE SENT TO US AND SOMEONE WILL CONTACT YOU BACK BY EMAIL OR PHONE. 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.

BABY VACCINATION REQUEST FORM

Baby's Name

First Name

Last Name

Date of Birth

Phone Number

Vaccinations requested

Two month

Four Month

Six Month

other

If other please specify below

Any other relevant information you think we should know:

Any other queries you have?

If you ned 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 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 sumit a form will be sent to us by email and you will get an acknowledgement back. We will contact you when we have our next available clinic date.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.

PRESCRIPTION REQUEST FORM

Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

Subject

Message

Is it your usual repeat prescription you require?

YES

If Yes; are there any items you do NOT require this time? Please write below

If it is not your usual prescription you require please specify your request below

Please specify your nominated pharmacy below:

All prescriptions will be forwarded directly to your pharmacy. There is no collections from the surgery of any items.

When you click on submit then an email will be sent to us with your request. We will endeavour to get your prescription ready as soon as possible and it will be sent electronically to your pharmacy. Please bear with us as we are extremely busy at the moment. There is a charge of €25 for private prescriptions, this will be added to your account.

REQUEST FOR MEDICAL CERTIFICATE

Name

First Name

Last Name

EIRCODE:

DATE OF BIRTH

Phone

(###)

###

####

PPSN

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?

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 and we would ask you to phone 057 9151247 to arrange payment by phone. Thank you

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.

Address:

ANTE-NATAL SERVICES REQUEST

Name

First Name

Last Name

DATE OF BIRTH

Phone

(###)

###

####

PPSN: we require this to claim fee for your antenatal visits from HSE.

WHAT SERVICE DO YOU REQUIRE?

ie is it a routine ante-natal check up? or a new pregnancy?

If it is a routine antenatal check up, when is your check up due?

WHEN YOU CLICK SUBMIT AN EMAIL WILL BE SENT TO US AND WE WILL CONTACT YOU WITH AN APPOINTMENT TIME AS SOON AS POSSIBLE, 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.

Our Address is: Primary care Centre, Banagher, BIRR, Co OFfaly R42 XW40

TEL: (057) 9151247 | Fax: (057) 9151513 |
Google MAP

Opening Hours

Monday - Friday: 9am - 6pm

Click for Appointment times & info

When we are closed, call MIDOC for Urgent Medical Services on 1850 302 702.

MIDOC operates 6pm to 8am weekdays and 24 hours on weekends and bank holidays.

********SCROLL TO THE VERY BOTTOM OF PAGE FOR COVID SCREENING FORM********

BELOW YOU WILL FIND REQUEST FORMS FOR

PRESCRIPTIONS, BLOOD TESTS, GENERAL MEDICAL ENQUIRIES, BABY VACCINATIONS, MEDICAL CERTIFICATES, ANTENATAL SERVICES & COVID-19 SCREENING FORM

PHLEBOTOMY / BLOOD TEST RESULTS REQUEST FORM

GENERAL MEDICAL PROBLEMS/OTHER ENQUIRIES

BABY VACCINATION REQUEST FORM

PRESCRIPTION REQUEST FORM

REQUEST FOR MEDICAL CERTIFICATE

ANTE-NATAL SERVICES REQUEST

NEW SCREENING FORM FOR ANYONE WITH SYMPTOMS SUGGESTIVE OF COVID 19 WHO MAY REQUIRE TESTING.

Our Address is: Primary care Centre, Banagher, BIRR, Co OFfaly R42 XW40

TEL: (057) 9151247 | Fax: (057) 9151513 | Google MAP

Opening Hours

SCROLL TO THE VERY BOTTOM OF PAGE FOR COVID SCREENING FORM

TEL: (057) 9151247 | Fax: (057) 9151513 |
Google MAP