New patient registration

The information I have provided is correct to the best of my knowledge. I will tell the practice about changes to my details, medicines or allergies. This form is not consent to any particular treatment.

Your details are used for registration, healthcare and administration. Please read the practice Privacy Statement at www.midletonmedicentre.ie/privacy-policy/ or ask reception for a copy.

Where someone signs for the patient, the practice will confirm their authority as appropriate.

Separate authorisation for your previous GP / practice. Complete and sign this section so that we can request your records from your previous GP. Please speak with reception if you do not have a previous GP or wish to discuss the transfer.

Your full name, date of birth and current address are already recorded earlier in this form. Please only complete the fields below if they are different, or if you'd like to authorise a records transfer.

I authorise my previous GP / practice named above to send a copy of my medical record to Midleton Medi Centre to support continuity of my care. This includes consultation notes, diagnoses, medicines, allergies, test results, referral letters, hospital correspondence and immunisation records.

Please discuss any concerns about the records to be transferred with a clinician before signing. You may withdraw this authorisation before the records are sent by contacting either practice.