After Tick Bite Prophylaxis 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
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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
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Prescription ConsultationOnline Consultation Fee
€25.00Edit
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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.
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Havens Pharmacy Macroom
Carrigtwohill Pharmacy
I prefer sending to another pharmacy
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Mulligan Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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Mulligans - Lisduggan Shopping Center
Mulligans - Smithlands
Mulligans - Tesco Ardkeen
Mulligans - Thomastown
Mulligans - City Square
Mulligans - Gladstone Street
Mulligans - Tesco Ballybeg
Mulligans - Kilmacthomas
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Molloy Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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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.
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SCANLONS PHARMACY, ENNIS RD BRANCH
SCANLONS EXPRESS LATE NIGHT PHARMACY, DOCK ROAD
SCANLONS PHARMACY, CASTLETROY BRANCH
LIMITLESS HEALTH PHARMACY
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McGorisks Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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McGorisks Pharmacy, The Crescent
McGorisks Pharmacy, Clonbrusk
McGorisk's Pharmacy, Ballinasloe
McGorisks Pharmacy, Athlone
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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.
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Date of Birth* This field is required.
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Phone Number* This field is required.
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Please specify your gender* This field is required.
MALE
FEMALE
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Did you remove the tick from your skin?* This field is required.
YESNO
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Are you pregnant, breastfeeding or are planning to get pregnant? (for females)* This field is required.
No
Not applicable - I am a male
Other
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Do you have any past medical or surgical history that you want to inform our doctor about?* This field is required.
NO
Other
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Do you have an allergy to any medications or substance?* This field is required.
NO
Other
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Declaration of consent.* This field is required.
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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