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FAQs » New Patients

1.

How do I register as a new patient in Elmwood?

We welcome any new patients who live within our practice area. If you wish to register with the practice then please come and visit the surgery in person, where our reception staff will take your details. Please fill out the following form and bring it with you.


Patient Registration 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

Surname:__________________ First name:________________

Known as:_____________________________________________

Title: Mr. /Mrs./Ms./ Other_______________________________

Date of birth:_____________________ Gender: Male / Female

Address:_____________________________________________

_____________________________________________________

Phone: Home:__________________ Work__________________

Mobile__________________

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

GMS number:__________________ Expiry date:____________

Next of kin:
Name:_______________________________________________

Address:______________________________________________

Relationship:__________________________________________

Phone:_______________________________________________

Previous GP name and address:__________________________
_____________________________________________________

Pharmacy name and address____________________________
_____________________________________________________

PPS 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.

Private Health Insurance Provider:_________________________

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:_ __________________________________________

Ethnic origin:__________________________________________

How did you hear about Elmwood Medical Practice?

____________________________________________________

____________________________________________________


Part 2 – Health History

Past Medical History:

_____________________________________________________

_____________________________________________________

_____________________________________________________

Last Smear Test & results
_____________________________________________________

Family Past Medical History:

_____________________________________________________

_____________________________________________________


Allergies:

Current medications:
If you are unsure you could bring your empty pill boxes with
you or get a printout from your pharmacist.
_____________________________________________________


Do you smoke?_______________________________________

Do you drink?________________________________________

When was the last time you visited a G.P.?
_____________________________________________________


Part 3 – Family Members

Do you have other family members already registered at Elmwood? If so, can you please provide us with the following:

Surname: ____________________ First name: ___________________
Date of birth: ________________
Surname: ____________________ First name: ___________________
Date of birth: ________________
Surname: ____________________ First name: ___________________
Date of birth: ________________
Surname: ____________________ First name: ___________________
Date of birth: ________________

Part 4 – Patient Statement

I_________________________________________ (Print Name)

have received a copy of the Data Protection Patient Information Leaflet

I_________________________________________ (Print Name)

have signed a separate consent to data processing;
__________________________________ __________________
Signature Date Date

2.

Can I register with a specific Doctor?

If you have a preference with regards to registering with a particular doctor, please make this known to the receptionist when registering.

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