Request Registration

Request for Registration for Private Patients

To ensure the best service for all our patients, it is essential that the registration form is completed accurately. If a patient registers as a private patient but is in fact a Medical Card holder, or provides any false information on the form, this will result in immediate removal from the GP’s care.

The GP reserves the right to refuse admission to any patient.

The form merely expresses an intention to register, and the GP will provide their approval or rejection via email as soon as possible.

First Name: Surname: Phone: Email: Address 1: Address 2: City: County: Eircode: PPSN: Date of Birth (dd/mm/yyyy):

I agree to the privacy policy.

I hereby confirm that all the information provided in this form is true and accurate to the best of my knowledge, and that I do not possess a medical card from the HSE.

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