Patient Registration Form

Patient Registration Form
Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Centric Health Practice in your local area
Title

Other
Twin
Home Address
Home Phone Number
Mobile Phone Number
Email
example@example.com
PPS Number (HSE-funded services may be applied for on your behalf where eligible, including programmes such as 'Cervical Check' and seasonal flu vaccination.)
Next of Kin Name

First NameLast Name
Next of Kin Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Details (if applicable)
Insurer Name
Membership Number
Medical Card Details (if applicable)
Medical Card Number
Expiry Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Medical History
Previous GP (Please provide the name and address of your previous GP practice and any relevant information regarding your medical records.)
Please note that the above-named patient has registered with our practice and has requested that their medical records be transferred to us.
List of current medication
Pharmacy Details

Pharmacy Name and address - where you want your prescriptions securely emailed by the practice.
Pharmacy name
Pharmacy address
Pharmacy Name and address - where you want your prescriptions securely emailed by the practice.
Communication Preferences

Please indicate Yes (Y) or No (N) for each option. You can withdraw your consent at any time by clicking the unsubscribe link in our emails or by contacting your practice. Withdrawing your consent will not affect your healthcare, your relationship with Centric Health, or any services you receive from us.
Patient Care Communications: I consent to receive text messages relating to my care (appointment reminders, information, test results etc) from this practice:
I consent to receive emails relating to my care (appointment reminders, information, test results etc) from this practice:
Centric Health Updates: I would like to receive new health information and advise, service updates and other communications from Centric Health.
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 Preferences

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.