Your name Address
Pharmacy of Choice: ---Collect In PracticeBurkes PharmacyTesco PharmacyMonread PharmacyStayWell David MurphyBoots MonreadVista Allcare PharmacyBoots Dublin RoadPoplar pharmacyFargreen PharmacyO’Reilly Care PlusO’Reilly PharmacySallins PharmacyMangan’s PharmacyLloyds PharmacyDaly’s PharmacyOther
Duration of Drug: One MonthThree MonthsSix Months
Comment