New Patient Registration

Do not use this form for emergencies or urgent clinical advice.

Secure patient intake

Adamstown Clinic New Patient Registration

Fields marked with * are required.

1. Patient Details

Surname *

Forename *

Address *

Eircode

Gender

PPS Number

Date of Birth *

Mobile Phone *

Home Phone

Email Address *

2. Medical Card / Insurance

Medical Card / Under 8 Card / Doctor Visit Card Number

Private Health Insurance

Provider

Policy Number

3. Emergency Contact / Next of Kin

Next of Kin Name

Phone Number

Relationship

4. Previous GP Information

Previous GP Practice Information

Doctor Name

Previous GP Address

5. Children Under Your Guardianship

Add children who should be included under this registration and consent process, where applicable.

Full Name

Relationship to You

Date of Birth

Full Name

Relationship to You

Date of Birth

Full Name

Relationship to You

Date of Birth

Full Name

Relationship to You

Date of Birth

6. Text Messaging Consent

Adamstown Clinic may use one-way text messages for appointment reminders, patient care reminders, normal result notifications or to ask you to contact the practice. Private medical information should not be communicated by text.

Text messages for patient care and appointment reminders I consent I do not consent

Text messages about investigation results I consent I do not consent

7. Medical Records Release Consent

I consent to the release of my medical records to Adamstown Clinic General Practice. Previous GP records may be securely transferred to: adamstownclinic.gp@healthmail.ie.

Patient Print Name

Date

8. Patient Data Consent

I authorise Adamstown Clinic General Practice to transfer my personal data where required for claiming and proving eligibility for illness, disability or relevant social protection schemes. I understand that this consent may be revoked in writing.

Patient Print Name

Date

9. Final Declaration & Signature

Typed Signature *

Date