New Patient Registration

New Patient Registration – Private GP Practice

This is a private GP practice. We do not participate in the Medical Card or HSE schemes. All consultations and services are privately billed.
SECTION 1 — Patient Identity Details
Title
First Name
Last Name
Date of Birth

DayMonthYear
Date
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 — GP Details
Do you have a GP?
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.
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.
Do you have a GP?
SECTION 4.1 — Previous GP Details
Previous GP Name
Previous GP Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
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?
Insurance Provider (if applicable)
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
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
Date
Parent Name
Consent of Parent
Should be Empty:

New Patient Registration – Private GP Practice

SECTION 1 — Patient Identity Details

SECTION 2 — Contact Information

SECTION 3 — Emergency Contact

SECTION 4 — GP Details

SECTION 4.1 — Previous GP Details

SECTION 5 — Private Health Insurance

SECTION 6 — GDPR & Consent (Mandatory Section)

SECTION 7 — Privacy Notice

SECTION 8 — Financial Acknowledgement

SECTION 9 — Declaration