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Call us on 01-278 3870
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Prescriptions
Doctors Letters
Services
Fees
New Patients
Send us an Email
Call us on 01-278 3870
Registration Form
Please fill out the below form is as much detail as possible.
Name
*
Email
*
Date of Birth
*
Gender
Your Address
*
Eircode
Phone Number
*
Mother's Maiden Name
PPS Number
*
Occupation
Next of Kin Name
*
Relationship to Patient
Next of Kin Phone Number
*
Current / Previous GP Name & Clinic Name
Do you have a medical card?
Yes, I do have a medical card or doctor visit card
No, I don't have a medical card
Medical card / doctor visit card number
Do you have private medical insurance?
Yes, I have private medical insurance
No, I don't have private medical insurance
Please detail any existing and past medical conditions
Please detail any past surgical proceedures and tests
Please detail any medications you are currently taking. Also include any over the counter medications.
Do you have a penicillin allergy?
*
Yes
No
Have you any allergies to medications?
*
Yes
No
Do your siblings, children or parents have any medical conditions?
Do you drink?
Yes
No
Do you smoke?
Yes
No
Please note that due to high demand there will be a temporary delay in arranging new patient consultations. This is to ensure that we can continue to deliver high-quality care to our existing patients. Thank you.
My family has already joined the practice and I need to make an appointment.
I have an appointment already and I would like to complete the registration before my visit.
I would like to join the waiting list.
Do you give consent to Rockcourt Medical to obtain your medical records from your previous or current GP, in accordance with Data Protection Regulation?
*
Yes, I give consent
No, I don't give consent
I have read and agree to the
privacy policy
Thank you! Your submission has been received!
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Opening Hours
Mon:
9am - 5pm
Tues:
9am - 5pm
Weds:
9am- 5pm
Thurs:
9am - 5pm
Fri:
9am - 5pm
Get in touch with us
(please phone if you are medically unwell as emails may not be read immediately)
Name
Email Address
Message
Thank you! Your submission has been received!
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