New Patient Registration

Use our form below to register as a new patient with us

Full Name

Date of Birth

Gender

Your Full Address

Phone

PPS Number

Do you have GP Visit Card/Medical Card?

Yes No

GP Visit Card / Medical Card Number

Do you have private health insurance?

Yes No

Insurance Policy Number

Do you consent to receiving text message alerts from the Killarney Medical Centre ?

Yes No

Current GP

Do you consent to requested medical notes if accepted as a patient?

Yes No

Reason for leaving current doctor

Pharmacy

Medical History (Past & Present)

List of Medication if any

By ticking this box I confirm that I have read and accept the privacy statement and consent to being contacted by Killarney Medical Centre.