Registration | LiffeyValley Medical

Registration Application

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.

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 and to arrange a registration visit.

Acceptance is only confirmed after this visit.

Please note that adults must complete their own separate form to register, however children can be included on a parent's application.

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

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Full Address (incl. Eircode)

Gender

Mobile Phone

Home Phone

PPS Number (required for certain free services)

Previous GP Name & Practice Name

Full Address of Previous GP

Do you have a medical card/doctor visit card?

Yes

Do you have private health insurance?

Yes

Please detail any exisiting or previous medical conditions:

Please detail any previous surgical procedures and/or tests:

Please detail all medication you are currently taking, including over the counter medications/supplements:

Are you allergic to penicillin?

Yes

Are you allergic to any medications?

Yes

Family History: Do your siblings, children or parents have any medical conditions?

Do you drink?

Yes

Do you smoke?

Yes

Do you have other family members who wish to join the practice?

Yes

The practice would like to contact you by text message (SMS) regarding appointment reminders, test results and practice updates.

Do you consent to be contacted by text message?

Yes, I consent to being contacted by SMS messages

No, I do not consent to being contacted by SMS messages

I understand that completing this form does not guarantee acceptance to the pracetice.

I consent to this practice obtaining my medical records from my previous practice, in accordance with Data Protection Legislation.

I consent to this message being sent electronically to the practice and consent to the practice contacting me on the email address and phone number provided.

I have read the practicePrivacy Statement.

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.

Signature

Registration Application

Contact

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