Apply to Join | The Swan Medical

PATIENT REGISTRATION

We aim to ensure the highest standard of medical care for our patients.

It is not possible to undertake medical care without collecting and processing personal data and data concerning health. Our policy is only to collect and record information about you that helps in your treatment.

Our practices are consistent with the Medical Council guidelines and the privacy principles of the Data Protection Acts.

Please complete the following form carefully. The information will be used to create your personal medical record on our patient management system.

Submitting this form does not guarantee acceptance to the practice.

First Name

Surname

Date of Birth (dd/mm/yyyy)

Address

Gender

Mobile Phone

Home Phone

PPSN (Optional)

*In order to provide certain health services, we require your PPSN, e.g. Vaccinations, Cervical Smears, Social Welfare Certs and other National Screening Programmes.

Medical Card Number

Next of Kin name

Next of Kin Contact Phone Name

Relationship to Patient

Previous GP Name and Practice Name

Previous GP Address

Details of any existing or previous medical conditions:

Details of any previous operations:

Details of any Allergies:

Are you allergic to any medications or Antibiotics?

Yes

If yes please provide details

Please read carefully and sign below to complete registration form.

I understand and consent to the practice obtaining my medical records from my previous GP if I am accepted into the practice, for the purposes of my ongoing healthcare and treatment.

I understand that providing my PPSN is optional and is required for providing certain health services as outlined above.*

I understand and consent to the practice collecting, using, and retaining my personal and medical data to provide the highest of medical care.

I understand that completing this form does not guarantee acceptance to the practice.

We like to contact our patients by text message regarding appointment reminders, test
results, vaccination clinics and other practice updates.

Do you consent to being contacted by text message?

Yes

I have read the practicePrivacy Statement.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

PATIENT REGISTRATION

Contact

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For Life Threatening Emergencies - Call 999 or 112