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Waiting List Registration

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 carefully. 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 Privacy Statement.

Submitting this form does not guarantee acceptance to the practice. A member of our team will contact you as soon as possible to advise if we currently have space on our list. 

Please note that omitting information on your application form may lead to the nullification of your application to join our medical practice.

If you would prefer to submit the form in writing, please contact reception for a form. 

Do you have a medical card/doctor visit card?
Do you have private health insurance?
Are you allergic to penicillin?
Are you allergic to any medications?
Do you drink?
Do you smoke?
Do you have other family members who wish to join the practice?

The practice would like to contact you by text message (SMS) regarding appointment reminders, test results and practice updates. 

Do you consent to be contacted by text message?

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

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