Registration | Moorefield Clinic

How do I Apply to Become a Patient with Moorefield Medical Clinic

Option 1

Apply to register as a Private Patient with our practice on the form below.

Option 2

I would like to register as a patient and would like to check my eligibility for:

Medical Card
Doctor Visit Card*
Under 8’s Card**
Over 70’s Card**
Carers Card

* Are you one of the thousands of people in Kildare with a net* income of €47,000, that have not applied for your Dr Visit Card. Net income = your gross income minus tax and other deductibles including mortgage, childcare, travel for work etc,

** Please note all children U8 are eligible for an U8’s card and all adults over 70 are eligible for an over 70’s card.

Find out if you or your family are eligible for free services.

Note - please use panel number 54432 - when applying for registration as a patient covered by any of the cards listed above.

Option 3

If you already have a Medical Card / GP Visit Card and would like to register with our practice, fill out this Change of General Practitioner Form - before delivering to one of our receptionists who will ensure your application form is completed and submitted.

Application to become a Private Patient

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Full Address

Eircode

Gender

Mobile Phone

Home Phone

PPS Number (required for certain free services)

Previous GP Name & Practice Name

Full Address of Previous GP

Next of Kin Name

Relationship to Patient

Next of Kin Phone Number

Do you have a medical card/doctor visit card?

Yes

Medical/Doctor Visit Card No.

Expiry Date

Do you have private health insurance?

Yes

Please detail any exisiting or previous medical conditions:

Please detail any previous surgical procedures and/or tests:

Please detail all medication you are currently taking, including over the counter medications/supplements:

Are you allergic to penicillin?

Yes

Are you allergic to any medications?

Yes

Please advise what medications you are allergic to:

Family History: Do your siblings, children or parents have any medical conditions?

Do you drink?

Yes

Do you smoke?

Yes

Do you have other family members who wish to join the practice?

Yes

Please provide each person's name, date of birth, PPSN, gender and Contact Details:

The practice would like to contact you by text message (SMS) regarding appointment reminders, test results and practice updates.

Do you consent to be contacted by text message?

Yes, I consent to being contacted by SMS messages

No, I do not consent to being contacted by SMS messages

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

I consent to this practice obtaining my medical records from my previous GP if I am accepted to the practice, in accordance with Data Protection Legislation.

I consent to this message being sent electronically to the practice and consent to the practice contacting me on the email address provided.

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.

How do I Apply to Become a Patient with Moorefield Medical Clinic

Application to become a Private Patient

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