New Patient Registration

New Patient Registration – Private Medical Practice

This is a private practice. We do not participate in the Medical Card or HSE schemes. All consultations and services are privately billed.
Children and Maternity Scheme Disclaimer: Our practice is not currently participating in the Children and Maternity Scheme, as we are awaiting confirmation of our application/status. Patients who are eligible under these schemes may still attend the practice privately if they wish; however, consultations and related services will be charged at the practice’s usual private fees and will not be provided free of charge under the scheme at this time.
Medical Practitioner Disclaimer: Consultations at our practice may be provided by either a General Practitioner or a Consultant in Internal Medicine. Both doctors provide private medical consultations within their professional scope of practice. However, certain certificates, statutory forms, government-related documentation, or scheme-specific services may require completion by a General Practitioner or by a doctor meeting specific eligibility requirements. Where this applies, you may be asked to book with the appropriate doctor, and an additional consultation or fee may apply.
SECTION 1 — Patient Identity Details
Title
First Name
Last Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
PPS Number (optional)
Preferred Name (optional)
SECTION 2 — Contact Information
Home Address

Street Address

Street Address Line 2
CityState / ProvinceEircode
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Landline (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
SECTION 3 — Emergency Contact
Emergency Contact Name
Relationship to Patient
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 4 Previous GP Details
Do you have a GP?
Previous GP Name
Previous GP Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I understand that CareBridge Medical does not accept Medical Cards and GP visits card and is a Private service. By registering with them I consent to the transfer of my records from my previous GP.
Disclaimer: Medical records are requested only after your Onboarding Consultation, if considered necessary by the doctor. Please note that transfer times depend on the previous healthcare provider and delays may occur. If you choose not to consent to the transfer of relevant medical records, this may limit or delay certain aspects of your care, including prescribing, certification, referrals, or ongoing management where the doctor considers previous information necessary for safe clinical decision-making.
If you have a Medical Card but wish to attend our GP, you can do so privately but you should NOT register under the practice.
SECTION 5 Private Health Insurance

This practice operates on a private fee-paying basis. Health insurance reimbursement (if applicable) is the responsibility of the patient.
Do you have private health insurance?
SECTION 6 Medical Background
Insurance Provider (if applicable)
Medical Background: (Please list all your previous diagnosis or surgeries)
Current Medication: (Please list all of your current medication)
SECTION 6 — GDPR & Consent (Mandatory Section)
I consent to this practice processing my personal and health data for medical diagnosis and treatment.
I consent to being contacted regarding appointments, test results, and medical care.
I consent to receiving appointment reminders via SMS.
I consent to relevant information being shared with hospitals, specialists, laboratories, and pharmacies where necessary for my care.
SECTION 7 — Privacy Notice
Privacy Notice

Data Controller: CareBridge Medical
Lawful Basis: Article 6(1)(b), 6(1)(c), and Article 9(2)(h) GDPR
Data is processed solely for healthcare provision and legal obligations.
Records retention: Minimum 8 years after last patient contact (or until age 25 for minors).
No data sold or used for marketing without separate consent.
No transfer outside EEA unless legally required.
Rights: Access, rectification, erasure, restriction, objection, and complaint to the Data Protection Commission Ireland.
Contact email for data protection queries: dpo@carebridgemedical.ie
Onboarding Consultation Requirement: By submitting this registration form, you acknowledge that an Onboarding Consultation is required at a fee of €60 before routine ongoing care can be established with the practice. This consultation allows the doctor to review your medical history, current treatment and healthcare needs, and to establish safe and appropriate care pathways.
SECTION 8 — Financial Acknowledgement
I understand this is a private fee-paying practice and I accept responsibility for all consultation and treatment fees.
SECTION 9 — Declaration
I confirm that the information provided is accurate and complete to the best of my knowledge.
Patient e-Signature
Parent/Guardian Signature (if patient is under 16)
Date (auto-generated on submission)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Name
Consent of Parent
Should be Empty:

New Patient Registration – Private Medical Practice

SECTION 1 — Patient Identity Details

SECTION 2 — Contact Information

SECTION 3 — Emergency Contact

SECTION 4 Previous GP Details

SECTION 5 Private Health Insurance

SECTION 6 Medical Background

SECTION 6 — GDPR & Consent (Mandatory Section)

SECTION 7 — Privacy Notice

SECTION 8 — Financial Acknowledgement

SECTION 9 — Declaration