Patient Registration Form

Submitting this form does not guarantee acceptance to the practice. A member of our team will contact you as soon as possible to advise if we currently have space on our list. If you are accepted as a new patient and have a chronic medical condition or take regular medications, we request that you arrange a registration consultation with a GP.

In order to provide for your care we need to collect and keep information about you and your health in your personal medical record. Please complete the following form carefully. The information will be used to create your personal medical record on the practice computer.

Our practices are consistent with the Medical Council guidelines and the privacy principles of the Data Protection Acts. For further details please see our Privacy Statement.

Please note that a separate form must be completed for each family member registering

If you would prefer to submit the form in writing, please contact reception for a form.

Please complete a form for each member joining the Practice.

First Name

Surname

Title

Date of Birth

Gender

Current Address

Eir Code

Phone: Home

Phone: Mobile

Previous Address

County of Birth

Occupation

GMS Medical Card Number

Expiry Date

Next of kin/ Name of contact person in case of emergency;

Name of next of kin

Relationship

Phone No.

Address

Previous GP Name and Address

Name of any clinics attended in the past three years

PPS Number: This is required for Social Welfare certification, Mother & Child Maternity Scheme, Cervical Check, Childhood vaccinations, flu virus vaccination for specific groups, etc.

PPSN

Private Health provider (where applicable)

We follow Data Protection Legislation in relation to all our patient information.

Please state the name of your preferred pharmacy for your prescriptions

I confirm you can forward all prescriptions directly to

I consent to receiving test messages regarding my care from this Practice

I consent to receiving emails regarding my care from this Practice

Please note that text messages and email correspondence can include appointment reminders, test results, and other Practice information.

Patient Registration Form

Contact

Opening Hours

Links

For Life Threatening Emergencies - Call 999