Request to Join

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Swords Family Practice

29/30 Brackenstown Village, Swords

Please Note: This is just a request, it does not guarantee your registration

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Full Address (incl. Eircode)

Gender

Mobile Phone

Current GP Name & Practice Name

Do you have a medical card/doctor visit card? *

Yes

Do you have private health insurance?

Yes

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

Yes

Please provide each person's name, date of birth

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.