Clinic 45 - Patient Form

Clinic 45 Consultation

Patient Form
Personal Details
Name

PrefixFirst NameLast Name
Date of Birth

DayMonthYear
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 blank area
Allergies to Medications
* If Yes, Please list here:
Taking any regular medications currently? ( i.e Aspirin, Inhaler, Cholesterol Tablet, Blood Pressure Tablet etc.)
If yes, please list it here
Other past/ongoing medical problems? Type NO if you don't have any
Consent Section
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Declaration

I confirm that the information I have provided to Clinic 45 is accurate and complete to the best of my knowledge.

I understand that the healthcare professionals at Clinic 45 may carry out medical assessments, examinations, investigations, and treatments as required for my care. I consent to receive treatment for minor injuries, minor surgical procedures, and aesthetic or cosmetic treatments where appropriate.

I understand that before certain procedures, the healthcare professional may need to mark or identify the treatment area on my skin or body to ensure the correct site is treated.

I acknowledge that the nature of the proposed treatment or procedure will be explained to me where appropriate, including potential risks, benefits, and alternatives, and I will have the opportunity to ask questions before treatment is carried out.

I understand that some procedures may involve minor discomfort, temporary side effects, or risks, and I agree to follow any instructions provided by the healthcare professional regarding preparation for treatment and aftercare.

I consent to my personal and health information being recorded, stored, and processed by the clinic for the purposes of providing medical care, maintaining medical records, arranging referrals, and communicating with other healthcare providers involved in my treatment. My medical information may be stored securely within the clinic’s electronic patient record system, including the Socrates Patient Management System.

I understand that my health information will only be accessed by authorised medical or administrative staff involved in my care and will not be disclosed to third parties without my permission unless required by law.

I understand that I have the right to request access to my personal data and that I may withdraw my consent for processing my health information at any time, subject to legal and medical record-keeping obligations.

By signing this form, I confirm that I understand and agree to the above statements and consent to treatment and the processing of my personal health data by Clinic 45.
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 Clinic 45 practice in writing
Signature/ Guardian's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Should be Empty:

Clinic 45 Consultation

Personal Details

Next of Kin

Consent Section