Child Registration | Maynooth GP Clinic

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Child 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.
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.

Date of Application

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Full Address (incl. Eircode)

Gender

PPS Number (required for certain free services)

Previous GP Name & Practice Name

Full Address of Previous GP

Next of Kin Name

Relationship to Patient

Next of Kin Phone Number

Do you have a medical card/doctor visit card? *

Yes

No

If so please state card number

Expiry Date

Do you have private health insurance?

Yes

No

Please detail any existing or previous medical conditions including hospitalisations:

Birth Weight and full term (>38 weeks) or premature?

Birth Location:

Any neonatal complications:

Childhood vaccines received and up to date? *

Yes

No

Please detail any previous surgical procedures and/or tests:

Please detail all medication you are currently taking, including over the counter medications/supplements:

Are you allergic to penicillin? *

Yes

No

Are you allergic to any medications? *

Yes

No

Please advise what medications you are allergic to:

Family History: Do your siblings, children or parents have any medical conditions?

Whom does the child live with?

Reason for changing GP?

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? *

Yes, I consent to being contacted by SMS messages

No, I do not consent to being contacted by SMS messages

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

I consent to this practice obtaining my medical records from my previous GP if I am accepted to the practice, in accordance with Data Protection Legislation.

I consent to this message being sent electronically to the practice and consent to the practice contacting me on the email address provided.

I have read the practicePrivacy Statement.

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.

Contact

Maynooth GP Clinic

The Leinster Clinic, Kilcock Road, Maynooth, Co. Kildare, W23 FW77

Phone: 01 912 5230

Out of Hours (KDOC): 045 848 701

Email (Health Professionals Only): maynoothgpclinic.gp@healthmail.ie

Opening Hours

Monday to Friday:

09.00-12.30 and 14.30-17.00

Weekends & Bank Holidays: Closed

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For Life Threatening Emergencies - Call 999

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