New Patient Register

Your details

Our Medical Card List is currently full. Please contact the surgery directly on 01 9636996 for enquiries.

We are delighted to welcome new medical-card and private patients to our practice. If you would like to register with our practice, please complete and sign the registration form below. Alternatively, this form can be picked up at the reception desk.

First Name *

Surame *

DOB (DD/MM/YY) *

Gender *

Email Address *

Address

Eircode *

Phone Number*

Medical card / doctor visit card number*

Do you have private medical insurance?

Please list all medical conditions previously diagnosed and any treatments or procedures you have had previously*

Please list all medications you are currently taking including the dosage instructions and any over the counter medications you also use*

Please list all know medication allergies or intolerances describing the issues experienced with these

Do you smoke and if so how many?

Do you consume alcohol and if so please outline your usual drinking habits ( standard drinks per week)?

Do you consent to receiving appointment updates by Text Message?

Yes No

Do you consent to receiving normal test results by Text Message?

Yes No

Please confirm you have read and agree to our privacy policy found here.

Please sign the form in the box below and click submit, or alternatively if you are unable to do that please print the form and return it to the receptionist.

We will contact you as soon as possible to arrange a new patient consultation. Thank you for choosing Airton Medical.

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New Patient Register

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