Migraine Treatment

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I confirm that I am 18 years of age or older, using this service voluntarily and on my own behalf. Any treatment or advice provided is intended solely for my personal use.* This field is required.
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Prescription Consultation* This field is required.
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$20
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costEUR
Prescription ConsultationOnline Consultation Fee
€25.00Edit
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Total cost €0.00
First Name
Last Name
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partner
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Burkes Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
Havens Pharmacy Macroom
Carrigtwohill Pharmacy
I prefer sending to another pharmacy
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McGorisks Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
McGorisks Pharmacy, The Crescent
McGorisks Pharmacy, Clonbrusk
McGorisk's Pharmacy, Ballinasloe
McGorisks Pharmacy, Athlone
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Molloy Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
Molloys Pharmacy - Garden Street, Ballina, F26 W951
Molloys Pharmacy - Bunree Road, Ballina, F26 Y9PF
Molloys Pharmacy - Main Street, Crossmolina, F26A4E3
Molloys Pharmacy - The Harrison Centre, Roscommon, F42 H002
Molloys Pharmacy - Ballaghaderreen, Co. Roscommon, F45X896
Molloys Pharmacy - Knocknacarra, Co. Galway, H91VPX2
Molloys Pharmacy - Davitt Quarter, Achill Island, F28V4P0
Molloys Pharmacy - Claremorris, F12RX02
I prefer sending to another pharmacy
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Scanlon Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
SCANLONS PHARMACY, ENNIS RD BRANCH
SCANLONS EXPRESS LATE NIGHT PHARMACY, DOCK ROAD
SCANLONS PHARMACY, CASTLETROY BRANCH
LIMITLESS HEALTH PHARMACY
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Full Pharmacy Name and Address is Required* This field is required.If Successful Your Script will be sent to this pharmacy.
If you do not provide correct details your application may be denied.
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
Confirm Email
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Country
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Date of Birth* This field is required.
Date
Day
Month
Year
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Phone Number* This field is required.
Area Code
Phone Number
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Please specify your gender.* This field is required.
MALE
FEMALE
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Please specify which treatment you are looking for? Please select Don't Know if you are not sure.* This field is required.
Please Select
Please Select
Sumatriptan 50mg (6 tablets)
Sumatriptan 100mg (6 tablets)
Imigran Nasal Spray 30mg (2 doses)
Imigran Nasal Spray 30mg (6 doses)
Don't know
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If others, please specify
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Did your migraine start after the age of 50?* This field is required.
YESNO
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Did you experience your first migraine attack last year?* This field is required.
YESNO
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Which healthcare professional diagnosed you with migraine?* This field is required.
Your doctor or specialist
Self diagnosis
Other
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Please specify the symptoms of your migraine?* This field is required.
Weakness on one side of your body
Vision loss or double vision
Uncoordinated or clumsy feeling
Ringing in the ears or trouble hearing
Unable to control parts of your body or speech
None of the above
Other
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If other, please specify.
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If you have a severe headache which is worse than previous migraines or you had recent head injury, sudden occipital headache or having fever and rashes on your body; you should attend Accident and Emergency.
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Do you have any past medical history of heart attack, angina, heart failure, stroke, TIA, leg claudication (circulation problems in your leg) that cause pain in your leg when you are walking?* This field is required.
No
Other
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Do you have any past medical history of high blood pressure, epilepsy, liver or kidney disease or any other medical or surgical condition that you want to inform our doctor?* This field is required.
No
Other
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Please answer the following question if they apply to you.* This field is required.
You have high cholesterol
A parent, brother or sister developed heart disease before they were 60
You smoke more than 10 cigarettes a day or use nicotine replacement therapies
You are diabetic
None of the aboveYou have high cholesterol
A parent, brother or sister developed heart disease before they were 60
You smoke more than 10 cigarettes a day or use nicotine replacement therapies
You are diabetic
None of the above
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If other, please specify:
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Are you currently taking any prescription, non prescription or illegal drug or herbal medication and have you recently taken any medication in the last two weeks?* This field is required.
No
Other
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Do you have an allergy to any medications or substances?* This field is required.
No
Other
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Attach a File/Photo of Your Regular Medications/Script (Optional)
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Select files to upload
Max. file size: 10.6MB
Cancelof
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Declaration of consent.
I understand the mentioned questions and I have answered them truthfully and to the best of my knowledge.
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GDPR Consent Form* This field is required.To assist with your care, we at Dooctor.ie need to collect personal data about you. This information will include details of your health and your treatments. We may also need to record additional information that while may not seem to relate directly to your health it would help in our treatment of you. Examples of this kind of information would include things like your age, gender, marital status, number of children you have, your nationality, your employment status, religion, prison sentences. Our policy is only to collect and record information about you that helps in your treatment. Declaration  I understand my health information will be seen or shared only with medical and administrative staff involved in my care or where Dooctor.ie is required to do so by law.  I understand that for the purposes of my treatment administrative staff may have to access my health data. Reasons for this access would include the re-issuance of prescriptions, the opening of letters and recording of information from hospitals about me, downloading and saving in my file results from laboratories, typing of letters to hospitals and other similar health related issues.  I understand that all Dooctor.ie staff sign a confidentiality agreement that binds them not to disclose my details to any unauthorised persons not involved in my care.  I understand that any health data shared outside of the practice for the purposes of my health treatment will, normally, be limited to information related to a particular treatment and not my entire file.  I understand that my health data will be stored primarily on a secure database operated by a specialist company called Clanwilliam Health and I understand that Clanwilliam Health are only allowed process my health data under Dooctor.ie instructions.  I understand the law provides that in certain instances personal health information can be disclosed, e.g. in the case of some infectious diseases.  I understand that Dooctor.ie will only release information to, for instance solicitors or insurance companies, at my express request.  I understand that I can withdraw consent for processing of my personal health data at any time.
I confirm my consent.
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