New Patient Registration Form

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex
Contact Number:*

Country Code(087, 085, 061..)Phone Number
E-mail*
Address:*

Street Address

Street Address Line 2

CityState / Province / County

Postal / Zip Code / Eircode
Next of Kin
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number:*

Country Code(087, 085, 061..)Phone Number
What medical symptom/problem have you attended us today? *
If confidential, please write CONFIDENTIAL in both blank area*
Allergies to Medications*

Yes*No
* If Yes, Please list here:
Taking any regular medications currently? ( i.e Aspirin, Inhaler, Cholesterol Tablet, Blood Pressure Tablet etc.)*

YesNo
If yes, please list it here
Other past/ongoing medical problems? Type NO if you don't have any*
Consent us to text about blood results/scan results etc.*

YesNo
Signature*

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Date

MonthDayYear
Date

Patient consent for processing of health data

To assist with your care, we at Dooctor.ie need to collect personal data about you. This information will include details of your health and your treatments. We may also need to record additional information that while may not seem to relate directly to your health it would help in our treatment of you. Examples of this kind of information would include things like your age, gender, marital status, number of children you have, your nationality, your employment status, religion, prison sentences. Our policy is only to collect and record information about you that helps in your treatment.

Declaration
- I understand my health information will be seen or shared only with medical and administrative staff involved in my care or where Dooctor.ie is required to do so by law.
- I understand that for the purposes of my treatment administrative staff may have to access my health data. Reasons for this access would include the re-issuance of prescriptions, the opening of letters and recording of information from hospitals about me, downloading and saving in my file results from laboratories, typing of letters to hospitals and other similar health related issues.
- I understand that all Dooctor.ie staff sign a confidentiality agreement that binds them not to disclose my details to any unauthorised persons not involved in my care.
- I understand that any health data shared outside of the practice for the purposes of my health treatment will, normally, be limited to information related to a particular treatment and not my entire file.
- I understand that my health data will be stored primarily on a secure database operated by a specialist company called Clanwilliam Health and I understand that Clanwilliam Health are only allowed process my health data under Dooctor.ie instructions.
- I understand the law provides that in certain instances personal health information can be disclosed, e.g. in the case of some infectious diseases.
- I understand that Dooctor.ie will only release information to, for instance solicitors or insurance companies, at my express request.
- I understand that I can withdraw consent for processing of my personal health data at any time.
PPSN
PPSN for Irish Resident only. Please type 0000 for Non-Irish Resident

The purpose of PPSN is for patient claiming Illness/Disability Schemes to the Department of Employment Affairs and Social Protection in future. This Consent can be revoked at any time by contacting Department or by informing Dooctor.ie practice in writing
Signature/ Guardian's Signature

Clear
Date

MonthDayYear
Date
Email
example@example.com
Email
example@example.com
Should be Empty: