Registration for new patients

Kinsealy Medical Centre welcomes patients with medical cards who do not currently receive care from a general practitioner. Patients will be required to fill out a patient registration form and sign a letter requesting access to their prior physician's medical records at their first appointment.

New Patient Form

The registration form will be assessed. Once registration has been approved access to medical treatment is available. On the registration date, access to medical treatment is available.

Name

First Name

Last Name

Email

Mobile Number

(###)

###

####

Date of Birth

MM

DD

YYYY

PPS Number

Home Address

Medical Card / DVC / under 6 card number (if any)

Current Medications ( + any drug allergies or previous allergies to vaccines)

Medical / Surgical History

Previous GP

Are you registering for Travel Vaccinations only? Yes/No

Yes

No

How did you hear about us?

I consent to the sharing of this medical information with the practice

Yes I consent

I consent to recieving text messages from Kinsealy Medical Centre

Yes I consent