Patient Registration Form

Patient Registration Form
Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Centric Health Practice in your local area*
Title

MaleFemaleTransgender (M)Transgender (F)Non-binaryGenderfluidPrefer not to SayOther
Twin*

YesNo
Home Address*
Home Phone Number
Mobile Phone Number*
Email*
example@example.com
PPS Number (Where National Health Services are available free of charge we will apply on your behalf e.g. Cervical Check, flu virus vaccination for specific groups etc.) *
Next of Kin Name

First NameLast Name
Next of Kin Number
Please enter a valid phone number.
Insurance Details (if applicable)
Insurer Name
Membership Number
Medical Card Details (if applicable)
Medical Card Number
Expiry Date

DayMonthYear
Date
Medical History
Previous GP
List of current medication
Pharmacy Details
Pharmacy Name and Location If you have a preferred Pharmacy, all prescriptions can be submitted directly. *
Communication

Please complete boxes with a Y – Yes and N – No
I consent to receive text messages relating to my care from this practice:*

YesNo
I consent to receive emails relating to my care from this practice:*

YesNo
I consent to receive emails/texts relating to marketing:*

YesNo
Please note that text messages and email correspondence can include appointment reminders, test results and other practice information.
Please note: submitting a registration form does not automatically place you under the care of this practice. All registration requests are reviewed and are subject to availability. Waiting lists may apply.
This General Practice is in partnership with Centric Health We adhere to Medical Council guidelines and principles of the Data Protection Legislation in relation to all our patient data. Further details are available in our Practice Privacy Statement. Practice Privacy Statement is displayed at www.CentricHealth.ie/PrivacyStatement . We would encourage you to read this or ask a member of our staff for a copy.
We prioritise patients who are not currently registered with a GP, as there is a high demand for new patient registrations. We are unable to accept patients who are already registered with a neighbouring surgery, as both practices operate the same policy. In addition, we can only accept patients who live within our designated catchment area. Our team will contact you once your request has been reviewed. If you have any questions in the meantime, or require urgent guidance, please contact the practice directly.
Should be Empty:

Patient Registration Form

Insurance Details (if applicable)

Medical Card Details (if applicable)

Pharmacy Details

Communication

Please note that text messages and email correspondence can include appointment reminders, test results and other practice information.

Please note: submitting a registration form does not automatically place you under the care of this practice. All registration requests are reviewed and are subject to availability. Waiting lists may apply.