Patients - General Application (restricted use)

General Intake Form 

Please fill in all the information as accurately as possible.

   Dr. Jody Shanahan-Prendergast


Irish Medical Council Register Number: 425861

How it Works?
Just €25 (100% money back guarantee).
Online consultations with Irish based doctors.
Discretely posted in a plain envelope with no branding.
Our doctors issue a 6 month prescription if medically safe and suitable.
Valid in any Irish pharmacy to buy your medication.
No risk, 100% refund if our Doctors cannot help you.
The information that you provide is covered by the same patient-doctor confidentiality as in a normal face to face consultation.


What is your birth sex? *

What Medical treatment are you looking for? *

Describe symptoms of illness (be as detailed as possible) *

Do you have any conditions affecting your heart or circulation including heart attacks, angina (chest pain), heart failure, a stroke or mini stroke, or claudication (cramping pain in yours legs when you walk)? *

Do you have any sensitivity to medicines or any allergies (Penicillin Allergy?)? *

Are you currently or in the last two months have you taken any medicine (prescribed or not), alternative medicines or recreational drugs? *

Other than conditions mentioned above, do you have any other significant medical conditions, illnesses or past surgical procedures?

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown) *

I confirm that I have read and understood this and my answers are fully correct and true. *

I confirm and agree that any treatment prescribed for me is for my personal use only. *