New Patient Form

Registration form

Birchwood Medical Clinic Patient Registration Form

In the case of a family or couple wishing to register, please note that a separate application must be submitted for each family member – thank you.

Personal Details

Address
Address
Address line 1
Address line 2 (optional)
City/Town
County
Eircode
Do you consent to being contacted via SMS messaging?
Example: school teacher
Next of Kin
Next of Kin
First
Last
Example: mother

Medical Information

leave blank if not applicable.
Do you have a medical card or doctor visit card?
Do you have private medical insurance?
Do you have a penicillin allergy?
Have you any allergies to medications?
Please list their relationship to you and the medical condition.
Do you smoke?
Do you drink alcohol?

Signature


Sign within the below field to confirm you you have read & agreed to Birchwood Medical Clinic’s privacy statement and wish to proceed with patient registration.

Draw or type your signature

Release of medical records

Do you wish to give consent to the Doctors in Birchwood Medical Clinic, to obtain your medical records from your previous GP, in accordance with Data Protection Regulation?

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