New Patient Registration

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

First Name

Surname

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

Private health insurance provider

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.