Registration | Ballymote Family Practice

Waiting List Registration

In order to provide for your care we need to collect and keep information about you and your health in your personal medical record. Please complete the following form carefully. The information will be used to create your personal medical record on the practice computer.

Our practices are consistent with the Medical Council guidelines and the privacy principles of the Data Protection Acts. For further details please see our Privacy Statement.

Submitting this form does not guarantee acceptance to the practice. A member of our team will contact you as soon as possible to advise if we currently have space on our list.

If you would prefer to submit the form in writing, please contact reception for a form.

Acceptable Proof of Address Examples (dated within the last 6 months)

Utility bills: Gas, electricity, television, broadband, waste, or fixed-line telephone/landline bills (printed online bills are accepted).
Financial statements: Bank statements, Building Society statements, or Credit Union statements/passbooks (note that digital-only or private lenders like Revolut are generally excluded by many registered organizations).
Government correspondence: Official letters or documents received from a government department or public agency (such as Revenue, Department of Social Protection, or SUSI).
Local authority documents: Letters from your local council or local authority confirming residency.
Other official items: Credit card statements or insurance policydocumentation (depending on the specific organization's exact compliance guidelines).

Documents That Are NOT Accepted

Mobile phone bills
Current driving licence (as a sole proof of address, though used for photo ID)
Store cards or catalogue statements

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Full Address (incl. Eircode)

Gender

Proof of Address

Upload File

Upload supported file (Max 15MB)

Mobile Phone

Nationality

PPS Number (required for certain free services)

Previous GP Name & Practice Name

Full Address of Previous GP

Why do you wish to change 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 existing or previous mental health 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

If you clicked yes to the above question, please complete an application for each member of your family.

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 declare that the information provided in this registration form is accurate, complete and truthful to the best of my knowledge. I understand that the disclosure of all relevant information regarding my health and healthcare needs is essential to ensure safe and appropriate care and to support the development of an effective and trusting therapeutic relationship from the outset of my registration. If you are accepted to the practice and it is subsequently found that you have been dishonest/untruthful with regard to details in your application, the practice reserves the right to review the therapeutic relationship.

I consent to adhering to the unacceptable behaviour, Zero-Tolerance practice policy

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.

Waiting List Registration

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