New Patients

Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Mobile) *

(###)

###

####

Phone (Other)

(###)

###

####

Sometimes we may need to contact you (e.g. for blood test results, reminders re appointments, etc). We use text messaging to inform patients of normal test results. You will generally be phoned directly if there are any abnormal test results. Texts are not used for advertising / general information about the surgery, they are only used for communicating specifically about your own care. *Please note that it is your responsibility to inform the practice if your contact details change* *

Please confirm that you CONSENT to be contacted by text message by ticking

Yes

No

Do you have private health insurance?

Yes

No

Do you smoke/vape: *

No, I do not smoke or vape

Smoke

Vape

INFORMATION FOR MEDICAL CARD PATIENTS

Your medical card covers you for visits to the GP for necessary medical care (acute illness, emergency treatment, etc). Most prescription medications are also covered (except for the DVC card, which is for GP appointments only). A number of services are not covered under the GMS contract and patients are required to pay directly for these services. These include: Sick notes (work certs) Specialised investigations – e.g. blood tests, warfarin monitoring Driving licence examinations including eye test Witnessing of forms – e.g. Passport and visa applications Doctor’s letters – e.g. to confirm you are a patient of the practice Wound dressings Medical examinations or reports for legal purposes (e.g. power of attorney) Well Man / Well Woman checks / annual medical examinations Examinations relating to insurance policies Pre-employment examinations School entry examinations Examinations in connection with fitness to take part in sports Some vaccinations – e.g. travel vaccinations Travel consultations Practices providing any of the above services are entitled to charge the patient directly. By checking this box you confirm you have read and understood the above.

I have read and understood the above information

New Patient information *

New Patient Forms and Information 1. This is an appointment-based service. Everyday we have appointments kept free and available to patients who require them to ensure that acute problems can be dealt with on the day, to avoid all appointments being booked in advance. For a same day appointment where you or your loved one need urgent care please call the surgery between 9am and 9.15am and between 2pm and 2.15pm and we will do our best to accomodate you. 2. If there are no appointments available, or you become ill outside of our hours, you will be directed to attend the out of hours service E-Doc in St. Colmcilles Hospital. The service is available between 6pm and 8am Mon – Fri, and 24hours over the weekend. Call 01 22 34 500. 3. Our GPs do not prescribe addictive medication such as benzodiazepines or morphine based medicines. 4. We have a duty to protect our diligent and caring staff. For this reason, any rudeness, aggression, or abusive behaviour towards our staff will result in your removal from our practice list. If you are unhappy with our service or feel you have been unfairly treated there is a complaints procedure on our website which should be followed. 5. Repeat prescriptions can be ordered on our website. Please only request items that you are prescribed on repeat – the GP’s can only prescribe new medication during an appointment. 6. For reasons of patient safety in prescribing, we require a minimum of 48 working hours notice for repeat prescriptions. Prescriptions will be sent to the pharmacy of your choice electronically within that timeframe. 7. All private patients fees are expected to be paid in advance, our fees are listed in the waiting room and on our website. 8. If you have difficulty climbing stairs, please let our staff know, an alert will be put on your chart to indicate you need to be seen in our downstairs consulting room. I confirm I have read and agree to the above information regarding practice

I have read and understood the above information

*

I understand that completing this form does not guarantee acceptance to the practice