Patient Registration and Medical History Form

In order to provide for your care, we need to collect and keep information about you and your health in your personal medical record. Please complete the following form. The information will be used to create your personal medical record on the practice computer.

Our practices are consistent with the Medical Council guidelines and the privacy principles of the Data Protection Acts. For further details please see our Practice Privacy Statement.

Part 1 - Personal Details

First name

Last name

Nickname

Title

Date of birth

Gender

Phone

Address

I am happy to receive alerts from the practice by phone:

Yes

Medical Card Number

Expiry Date

PPS number

Next of kin

Relationship

Phone

Previous GP Name and Address

Pharmacy Name and Address

PPSN number: To avail of certain governmental schemes (e.g. Social welfare certificates, Mother and Child Maternity Scheme, Cervical Check, Childhood vaccinations) it will be necessary for you to provide us with your PPSN number.

Further information: The following information is not essential but may be of use to your doctor when they are diagnosing a problem or deciding on a treatment plan for you.

Marital status

Occupation

Ethnicity

Part 2 - Health History

Allergies

Medical history

Surgical history

Current medication (if you are unsure, bring your empty pill boxes with you or get a printout from your pharmacist)

Patient statement

I confirm I have read the Practice Privacy Statement