Registration Form

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Aungier Street Clinic Temporary Registration Form

  1. All patients who wish to attend this clinic but live outside Dublin 2, it is advisable to have their primary general practitioner close to their residence, as our doctors cannot provide house calls outside Dublin 2. House calls are reserved for emergencies only.
  2. It is our policy not to provide receipts at a later date so we request all patients to obtain receipts at the time of consultation.
  3. Any patient who is abusive towards a member of staff or does not wish to adhere to practice policies will be removed.
  4. Patients under the age of 16 must be accompanied by their parent.

Date*

Your Email*

Surname (Family Name)*:

Forename (First Name)*:

Date of Birth*

Sex*:

Address*:

Home Phone:

Work:

Mobile:

Occupation*:

Nationality*:

Marital Status*:

Other, please state:

Do you or have you ever suffered from any of the following?

Asthma*:

Diabetes:

Heart Disease*:

Epilepsy*:

High Blood Pressure*:

Varicose Vein*:

Migraine / Severe Headache*:

Other (Please specify):

Any Major Surgeries:

Do you smoke*?

If yes, how many per day*?

Do you drink*?

Do you have any allergies*?

If yes, please state:

Are you taking any medication*?

If so, please state what medication you are on, including the pill:

Emergency Contact Person:

Name*:

Phone number*:

Relationship to you*:

How Did You Find Out About Our Clinic*?

Which internet search engine?
Please state:

Do you give us permission to contact on phone and text?*

ALL FEES TO BE PAID PRIOR TO CONSULTATION THANK YOU

*Required fields