Prescription Registration

Registration - Nov 2021

Step 1 of 8

About you
I am setting up prescriptions for
- Just myself
- Myself and my family
- Person(s) I care for

Carer Details
Name
First Last
Contact Number
Contact Email
Enter Email Confirm Email
First Member
Personal Details
Name*
First Last
Date of birth*

Day
Month
Year
Gender*
Contact details
Email*
Enter Email Confirm Email
Phone

Add family members
Would you like to add a second adult member ?*
2nd Adult member
2nd Adult member*
First name Last name
2nd Adult date of birth*
DD slash MM slash YYYY
2nd Adult Gender*
2nd Adult Phone
Children
Would you like to add a child to your account ?*
Child 1
Child 1*
First name Last name
Child 1 date of birth*
DD slash MM slash YYYY
Child 2
Child 2*
First name Last name
Child 2 date of birth*
DD slash MM slash YYYY
Child 3
Child 3*
First name Last name
Child 3 date of birth*
DD slash MM slash YYYY
Child 4
Child 4*
First name Last name
Child 4 date of birth*
DD slash MM slash YYYY

Billing address
Address*
Address City / Town
Address 3 (optional)
County*
Eircode (optional)
Delivery address
Same as billing address*
- Yes
- No
Address*
Address 1 Address 2
Address 3 (optional)
County*
Eircode (optional)

Your Prescriptions
Adding 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?
Medical Card Number
Do you have a Drugs Payment Scheme (DPS) card?
DPS Card Number
Do you have a Long Term Illness card?
Long Term Illness Number

Create Password
Enter a password so you can login to your account
Password*
Enter Password Confirm Password

Review Your Information
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Confirmation
Membership Number
Consent*
I have read & agree to the Privacy Policy and Terms & Conditions
Prescription 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.