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 each patient must complete a separate registration form.
If you would prefer to submit the form in writing, please contact reception for a form.
MEDICAL CARD HOLDERS (INCLUDING UNDER-8 AND OVER-70S CARD HOLDERS)
If you are a medical card holder, please request an HSE Change of Doctor form from reception. You will be charged for consultations at our surgery until you have signed the form and your card has been transferred to one of our doctors' GMS lists.
PERSONAL DATA PROCESSING CONSENT
DISCLAIMER
If you agree to the Practice contacting you using the telephone number provided above, the number will only be used in relation to your ongoing healthcare, including appointment reminders, GP requests, screening opportunities and test results. It will not be passed to another party. You may opt out at any time by contacting the Practice; requests will be actioned within 48 hours.
By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.
