{"id":927,"date":"2023-11-01T14:48:14","date_gmt":"2023-11-01T14:48:14","guid":{"rendered":"https:\/\/belgraveclinic.com\/?page_id=927"},"modified":"2024-02-23T09:28:55","modified_gmt":"2024-02-23T09:28:55","slug":"repeat-prescription","status":"publish","type":"page","link":"https:\/\/belgraveclinic.com\/repeat-prescription\/","title":{"rendered":"Repeat Prescription"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"927\" class=\"elementor elementor-927\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b34878e elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"b34878e\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-29e542c\" data-id=\"29e542c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c5caa10 elementor-widget elementor-widget-text-editor\" data-id=\"c5caa10\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 25-04-2024 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>The repeat prescription ordering service applies to long-term repeat medications only. All requests will be reviewed by a GP and you may be asked to make an appointment in relation to your request.<\/p><p>We ask for an itemised request which helps reduce the risk of medication errors.<br \/>We will accept a written\/itemised request using a prescription request form available from reception or you can use the adjacent electronic request form.<\/p><p>Please allow <strong>48 hours<\/strong> for your request to be processed, you will receive a text when your prescription has been sent to your nominated pharmacy.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-8051731\" data-id=\"8051731\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-80ab247 elementor-widget elementor-widget-heading\" data-id=\"80ab247\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 25-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">Repeat Prescription Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3fdd992 elementor-widget elementor-widget-text-editor\" data-id=\"3fdd992\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_safari gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/927' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><label class='gfield_label gform-field-label' for='input_1_1'>Your full name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Your phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Your address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><legend class='gfield_label gform-field-label' >Please select a category<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_4'>\n\t\t\t<div class='gchoice gchoice_1_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Private patient'  id='choice_1_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>Private patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Full medical card'  id='choice_1_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>Full medical card<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='GP visit card (including over 70s medical card and under 8 medical card)'  id='choice_1_4_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_2' id='label_1_4_2' class='gform-field-label gform-field-label--type-inline'>GP visit card (including over 70s medical card and under 8 medical card)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Free contraceptive scheme'  id='choice_1_4_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_3' id='label_1_4_3' class='gform-field-label gform-field-label--type-inline'>Free contraceptive scheme<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\" ><label class='gfield_label gform-field-label' for='input_1_45'>Please add your medical card number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>How will you collect your prescription?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='I will collect it from the reception desk' >I will collect it from the reception desk<\/option><option value='I will collect it at a pharmacy' >I will collect it at a pharmacy<\/option><\/select><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Please add the name and address of your preferred pharmacy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'    placeholder='example: Bourke&#039;s Rathmines' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>1. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><label class='gfield_label gform-field-label' for='input_1_53'>Duration of Drug 1<\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_1_53' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><label class='gfield_label gform-field-label' for='input_1_31'>Dose of Drug 1<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><label class='gfield_label gform-field-label' for='input_1_54'>Strength of Drug 1<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>2. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\" ><label class='gfield_label gform-field-label' for='input_1_55'>Duration of Drug 2<\/label><div class='ginput_container ginput_container_select'><select name='input_55' id='input_1_55' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\" ><label class='gfield_label gform-field-label' for='input_1_72'>Dose of Drug 2<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><label class='gfield_label gform-field-label' for='input_1_32'>Strength of Drug 2<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_73\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' for='input_1_13'>3. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><label class='gfield_label gform-field-label' for='input_1_56'>Duration of Drug 3<\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_1_56' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_71\" ><label class='gfield_label gform-field-label' for='input_1_71'>Dose of Drug 3<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_1_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><label class='gfield_label gform-field-label' for='input_1_33'>Strength of Drug 3<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_75\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><label class='gfield_label gform-field-label' for='input_1_34'>4. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_1_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><label class='gfield_label gform-field-label' for='input_1_57'>Duration of Drug 4<\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_1_57' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\" ><label class='gfield_label gform-field-label' for='input_1_70'>Dose of Drug 4<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Strength of Drug 4<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_76\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_76\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><label class='gfield_label gform-field-label' for='input_1_11'>5. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" ><label class='gfield_label gform-field-label' for='input_1_58'>Duration of Drug 5<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_1_58' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_69\" ><label class='gfield_label gform-field-label' for='input_1_69'>Dose of Drug 5<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>Strength of Drug 5<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_77\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>6. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><label class='gfield_label gform-field-label' for='input_1_59'>Duration of Drug 6<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_1_59' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\" ><label class='gfield_label gform-field-label' for='input_1_68'>Dose of Drug 6<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_1_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Strength of Drug 6<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_78\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>7. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><label class='gfield_label gform-field-label' for='input_1_60'>Duration of Drug 7<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_1_60' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\" ><label class='gfield_label gform-field-label' for='input_1_67'>Dose of Drug 7<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><label class='gfield_label gform-field-label' for='input_1_23'>Strength of Drug 7<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_79\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_79\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>8. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\" ><label class='gfield_label gform-field-label' for='input_1_61'>Duration of Drug 8<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_1_61' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><label class='gfield_label gform-field-label' for='input_1_66'>Dose of Drug 8<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_1_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><label class='gfield_label gform-field-label' for='input_1_26'>Strength of Drug 8<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><label class='gfield_label gform-field-label' for='input_1_39'>9. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><label class='gfield_label gform-field-label' for='input_1_62'>Duration of Drug 9<\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_1_62' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><label class='gfield_label gform-field-label' for='input_1_65'>Dose of Drug 9<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Strength of Drug 9<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_81\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><label class='gfield_label gform-field-label' for='input_1_40'>10. Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_1_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_63\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><label class='gfield_label gform-field-label' for='input_1_63'>Duration of Drug 10<\/label><div class='ginput_container ginput_container_select'><select name='input_63' id='input_1_63' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >One month<\/option><option value='Second Choice' >Three months<\/option><option value='Third Choice' >Six months<\/option><\/select><\/div><\/div><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\" ><label class='gfield_label gform-field-label' for='input_1_64'>Dose of Drug 10<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><label class='gfield_label gform-field-label' for='input_1_30'>Strength of Drug 10<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><label class='gfield_label gform-field-label' for='input_1_41'>Notes about your prescription<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_1_41' class='textarea large'  aria-describedby=\"gfield_description_1_41\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_41'>This is only for remarks about your prescription. For any clinical concerns or queries, please contact us by telephone.<\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_1_48 gfield_product_1_48 field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_1_48_1'>Repeat Prescription fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_48.1' value='Repeat Prescription fee' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_1_48' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_1_48' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_48.2' id='ginput_base_price_1_48' class='gform_hidden' value='20,00 &#8364;' aria-label='Repeat Prescription fee Price'  \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input type='hidden' name='input_48.3' value='1' class='ginput_quantity_1_48 gform_hidden' \/>\n\t\t\t\t<\/div><\/div><fieldset id=\"field_1_47\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_47.1' id='input_1_47_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_47_1' >I consent to receiving a notification text regarding my prescription.<\/label><input type='hidden' name='input_47.2' value='I consent to receiving a notification text regarding my prescription.' class='gform_hidden' \/><input type='hidden' name='input_47.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_49\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" >PRESS SUBMIT TO PROCEED TO PAYMENT<\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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