Eldon Family Practice - Application-to-Register Form

Eldon Family Practice - Application-to-Register 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.
First Name*
Last Name*
Name

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Eircode*

Street Address

Street Address Line 2

CityState / Province
Mother's Maiden Name
PPS*
Phone Number*

Country CodeArea CodePhone Number
Do you consent to being contacted via SMS messaging?*

Yes, I give consent to being contacted by SMS.No, I do not give consent to being contacted by SMS.
Email
example@example.com
What is your occupation?
Example: School Teacher
Next of kin name*

First NameLast Name
What is the next of kin's relationship to the patient?
Example: Mother
Next of kin's phone number*

Country CodeArea CodePhone Number
Previous / current GP name & clinic name
leave blank if not applicable.
Do you have a medical card?*

Yes, I do have a medical card or doctor visit card (insert details below)No, I do not have a medical card
Medical card / doctor visit card number:
leave blank if not applicable.
Do you have private medical insurance?*

Yes, I have private medical insuranceNo, I do not have private medical insurance
Private medical insurance provider
leave blank if not applicable.
Private medical insurance policy number
leave blank if not applicable.
Please outline any medical conditions you have been diagnosed with:
Please outline any surgical procedure / tests you have had in the past:
Please outline any prescribed or over the counter medications you are taking, including the dose:
Do you have a penicillin allergy?

Yes, I do have an allergy to penicillinNo, I do not have an allergy to penicillin
Have you any allergies to medications?*

Yes, I do have allergies to medicationsNo, I do not have allergies to medications
You answered yes to the last question, what reactions have you had to the medication/s?
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, I do smoke.No, I do not smoke.
You answered yes to the last question, how many do you smoke daily?
Do you drink alcohol?*

Yes, I drink alcohol.No, I do not drink alcohol.
You answered yes to the last question, how many drinks do you have each week?
Please note that due to high demand there will be a temporary delay in arranging new patient consultations. This is to ensure that we can continue to deliver high-quality care to our existing patients. Thank you.*

My family has joined the practice, and I need to book an appointment.For now I would just like to join the waiting list. We will contact you to advise what the current wait time is.
Thank you, someone from the Eldon Family Practice team will reach out soon in order to organize an appointment.
Thank you, we look forward to seeing you soon in Eldon Family Practice.
Thank you for joining the waiting list to sign up to the practice. We will contact you when a new space becomes available. If you have an urgent query, you can contact us via the options found on the 'contact us' page on the Eldon Family Practice website.
Sign within the below field to confirm you you have read & agreed to Eldon Family Practice's privacy statement and wish to proceed with patient registration.
Signature

Clear
Release of medical records
Do you wish to give consent to the Doctors in Eldon Family Practice, to obtain your medical records from your previous GP, in accordance with Data Protection Regulation?*

Yes, I give consent.No, I do not give consent.
Please fill in your previous GP's details in the blank spaces below.
I give consent to Dr. your previous GP's name of Their practice address to release my medical records to the doctors of Eldon Family Practice in accordance with Data Protection Regulation.
Please confirm your name

First NameLast Name
Please confirm your date of birth

DayMonthYear
Do you wish to give consent to the release of your dependents’ records. All patients aged 16 or over must individually consent and sign.

I give consent to the named doctor above, to also release the medical records of my dependents listed below.I do not have dependents, or do not wish to release the medical information for my dependents.
List dependents name's & their date of birth
Further application information
More information 2
Sign within the below field to confirm you authorize the release of your medical records, as above stated.
Signature

Clear
Should be Empty:

Eldon Family Practice - Application-to-Register 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.

Release of medical records