Application for Patient RegistrationInchicore Family DoctorsPrimary Care CentreSt Michaels EstateDublin 8 PERSONAL DETAILS Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Daytime Telephone number * (###) ### #### Other Telephone number (###) ### #### Email Nationality * First language * FAMILY MEMBERS Name of Next of Kin * First Name Last Name Next of Kin Telephone number * (###) ### #### Do you consent to us contacting your next of kin if necessary Yes No Other family members to be registered Please provide a full name and date of birth for each additional family member to be added MEDICAL CARD If you own a medical card always present it at reception when visiting Do you own a current Medical Card - if Yes, please enter your GMS number below * Yes No GMS number Expiry Date MM DD YYYY VACCINE QUESTIONNAIRE Children under 5 years, what vaccines has your child received? Have you ever received the flu vaccine? * Yes No When was the last time you received the flu vaccine? Month / Year Have you ever received the pneumonia vaccine? Yes No When was the last time you received the pneumonia vaccine? Month / Year PREVIOUS GP To ensure we are providing you with the best care possible, it is standard practice to request your medical records from your previous GP. Please enter details below: Name & Address of previous GP CONSENT We use text messages to send results of investigations & to communicate to patients regarding appointments/private accounts Do you consent to having your medical records released to Inchicore Family Doctors Yes No I consent to have results of my investigations sent by text * Yes No I consent to have appointment/account reminders sent by text * Yes No Processing of Health Data * Tick this to consent for Inchicore Family Doctors to process your personal data, include health information, for the purpose of your on-going health care treatment. Yes, I consent to Inchicore Family Doctors processing my personal data and health information No, I do not consent to Inchicore Family Doctors processing my personal data and health information Do you consent to a relative/friend collecting personal data on your behalf * Yes No Name of person nominated LASTLY... How did you hear about our practice? Thank you for filling out our Patient Registration form. We will be in touch shortly.
