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

You may opt to receive results, reports, or certificates from us via email. Please be advised that email is not a secure method of communication. For your convenience, hard copies can always be collected from our reception. We will only send results, reports, or certificates in response to an email request directly from the patient. From a GDPR standpoint, we are obligated to inform you that sending clinical information via regular email is not secure. If you still wish to receive your results via email, please sign below to indicate that:

You have read and understand this information.
You consent to your information being sent via non-secure email.
Alternatively, you can request to have your results printed and collect them from reception

Your Full Name*

Signature*

Previous GP Name & Address*

I consent to my medical information & medical records from my previous GP be sent to Rahona Family Practice*

Yes

Please be assured that any identifiable information about you will only be shared with nurses, hospitals, and other healthcare providers directly involved in your care, ensuring you receive the best possible treatment.

Your Full Name*

Signature*

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

Name

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