Request Registration

Request to Transfer Medical Records

Patient

First Name: Surname: Patient's Email: Date of Birth (dd/mm/yyyy): PPSN:

Previous GP

Previous GP Name: Previous GP Address: Previous Doctor:

You need to obtain the email address ending in @healthmail.ie from your previous GP. If you don’t have it or have a different email address that ends differently, unfortunately, we won’t be able to process your request. We recommend calling your previous GP and asking them for their healthmail.ie address.

Previous Doctor's Email:

I hereby request that my medical records be transferred to My Family Doctor in Tallaght, (Dr. Pilar Galdón Blesa).

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