Prescription Registration Registration - Nov 2021 Step 1 of 8 12% About youI am setting up prescriptions for Just myself Myself and my family Person(s) I care for Carer DetailsName First Last Contact NumberContact Email Enter Email Confirm Email First MemberPersonal DetailsName* First Last Date of birth* Day Month Year Gender*MaleFemaleContact detailsEmail* Enter Email Confirm Email Phone Add family membersWould you like to add a second adult member ?*NoYes2nd Adult member2nd Adult member* First name Last name 2nd Adult date of birth* DD slash MM slash YYYY 2nd Adult Gender*MaleFemale2nd Adult PhoneChildrenWould you like to add a child to your account ?*No1 child2 children3 children4 childrenChild 1Child 1* First name Last name Child 1 date of birth* DD slash MM slash YYYY Child 2Child 2* First name Last name Child 2 date of birth* DD slash MM slash YYYY Child 3Child 3* First name Last name Child 3 date of birth* DD slash MM slash YYYY Child 4Child 4* First name Last name Child 4 date of birth* DD slash MM slash YYYY Billing addressAddress* Address City / Town Address 3 (optional) County*CarlowCavanClareCorkDonegalDublin CountyGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklowAntrimArmaghDerryDownFermanaghTyroneDublin 1Dublin 2Dublin 3Dublin 4Dublin 5Dublin 6Dublin 7Dublin 8Dublin 9Dublin 10Dublin 11Dublin 12Dublin 13Dublin 14Dublin 15Dublin 16Dublin 17Dublin 18Dublin 19Dublin 20Dublin 21Dublin 22Dublin 23Dublin 24Dublin 6WEircode (optional) Delivery addressSame as billing address* Yes No Address* Address 1 Address 2 Address 3 (optional) County*CarlowCavanClareCorkDonegalDublin CountyGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklowDublin 1Dublin 2Dublin 3Dublin 4Dublin 5Dublin 6Dublin 7Dublin 8Dublin 9Dublin 10Dublin 11Dublin 12Dublin 13Dublin 14Dublin 15Dublin 16Dublin 17Dublin 18Dublin 20Dublin 22Dublin 24Dublin 6WEircode (optional) Your PrescriptionsAdding your card numbers here will speed up the processing time for your prescriptions.How would you like your medications packed? Original packaging PillPods Do you have a medical card?NoYesMedical Card Number Do you have a Drugs Payment Scheme (DPS) card?NoYesDPS Card Number Do you have a Long Term Illness card?NoYesLong Term Illness Number Create PasswordEnter a password so you can login to your accountPassword* Enter Password Confirm Password Review Your Information{all_fields:nohidden,nopricingfields,exclude[22,54]} ConfirmationMembership NumberConsent* I have read & agree to the Privacy Policy and Terms & ConditionsPrescription Requirement* I understand that to order prescription medications for delivery, a prescription from a GP or online doctor must be sent to Healthwave. Prescriptions can be sent electronically by the doctor via Healthmail ePrescription or sent by post to us by you. Δ
