Registration form Birchwood Medical Clinic Patient Registration FormIn 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 First Name * Last Name * Date of Birth * Gender * MaleFemaleOther GenderAddress * Address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City/Town City/Town County County Eircode Eircode PPSN number * Mother’s Maiden name * Your Email * Phone Number * Do you consent to being contacted via SMS messaging? * Yes No What is your occupation? * Example: school teacherNext of Kin * Next of Kin First First Last Last What is the next of kin’s relationship to the patient? * Example: mother Next of Kin phone number * Medical Information Previous / current GP name & clinic name leave blank if not applicable.Do you have a medical card or doctor visit card? * Yes No Medical card or doctor visitor card number Do you have private medical insurance? * Yes No Please outline any medical conditions you have been diagnosed with. (optional) Please outline any surgical procedure / tests you have had in the past. (optional) Please outline any prescribed or over the counter medications you are taking, including the dose. (optional) Do you have a penicillin allergy? * Yes NoHave you any allergies to medications? * Yes No Which medications are you allergic to? Do your parents, siblings or children suffer from any medical conditions? * Please list their relationship to you and the medical condition.Do you smoke? * Yes NoDo you drink alcohol? * Yes No Is there anything else you would like us to know? Signature * I consent to being contacted by Birchwood Medical Clinic about this application. * * I have read and agree to the privacy statement *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. Signature * signature keyboard Clear Draw or type your signatureRelease of medical recordsDo 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? * Yes No If you are human, leave this field blank. SubmitΔ
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