D4. Dispensing_Suspected Forgeries

First name *

Last name *

Email address *

Pharmacy name *

Pharmacy registration number *

Country / Region *Ireland

Street address *

Apartment, suite, unit, etc. (optional)

Town / City *

County * Select an option…CarlowCavanClareCorkDonegalDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklow

Eircode (optional)

Phone *