New Patient Registration » Rahona Family Practice

Step 1 of 5 - About you

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Your First Name(s)*

Your Last Name*

Your Date of Birth*

Gender / Preferred Pronoun*

Full Address (including Eircode)*

Your Phone Number*

Your Email*

Occupation*

Marital Status*

Your PPS Number*

Your Medical Card or GP Visit Card Number

Your Health Insurance Provider

Next of Kin

Full Name (Next of Kin)*

Relationship*

Phone Number*

Medical History

Have you been diagnosed with any medical conditions? Have you ever been hospitalised?*

Yes

Please provide further details*

Surgical History

Have you had any surgery?*

Yes

Please provide further details about your surgical history*

Medications

Current Medications*

Please include anything ‘over the counter’ or non-prescription medications. Please detail any medications you have taken before which have been ineffective.

Drug Allergies*

Please provide full details if you have any drug allergies

Family History*

Please provide details of your relevant family medical history.

Are you a smoker or an ex-smoker?*

Never smoked

Current smoker

Ex-smoker

How many cigarettes per day do you smoke?*

When did you quit?*

Do you vape?*

Yes

Do you drink alcohol?*

Yes

How many units per week?*

1 pint = 2 units; 1 small glass wine = 1 unit; 1 short = 1 unit

Are you registered for the following national screening programmes?

Bowel Screen for all adults age 60-69

Breast Check for females age 50-69

Cervical Check for females age 25-65

Consent

I consent to receive information*

Yes, via both Email and Text (SMS)

Yes, via Email only

Yes, via Text (SMS) only

Your Full Name*

Signature*

Previous GP Name & Address*

I consent for my medical information to be sent to Rahona Family Practice*

Yes

Your Full Name*

Signature*

By submitting this form you accept our policies in Rahona Family Practice.

Phone

This field is for validation purposes and should be left unchanged.