✆ 0818888444 - GP Line

✆ 0818888333 - Community Nurse Team

Patient Registration

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✉ gp@recoveryhealthcare.ie

✉ admin@recoveryhealthcare.ie

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Patient Registration

0818888444

Patient Registration

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

Next of Kin Name

Next of Kin Name Relationship to Patient

Next of Kin Phone Number

Do you have a medical card/doctor visit card? *

Yes

Do you have private health insurance?

Yes

No 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

Reason for changing GP?

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 practice.

I consent to this practice obtaining my medical records from my previous GP if I am accepted to the 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 provided.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. 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.

Thank you!

Recovery Healthcare

Address

67 Eccles Street

Dublin 7

DUBLIN,

D07 Y76V

0818888444 - GP Line

0818888333 - Community Nurse Team

admin@recoveryhealthcare.ie

gp@recoveryhealthcare.ie

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