Free template
Patient registration form template
The first page every new patient fills in, laid out for an Irish private practice: GP, insurer and medical card in one place.
Download the PDFFree, no sign-up. Fill it in on screen or print it.
What it asks for
What is on the formThe patient completes
- Personal details: full name, date of birth, gender, PPSN, marital status and occupation
- Contact: phone, email and address
- GP: name, practice and phone
- Cover: medical card number, insurer and policy number
- Emergency contact
- Clinical: allergies, current medications and medical history
- A privacy acknowledgement and the patient's or representative's signature
Using it well
- Point the acknowledgement at your practice's own privacy notice, so the patient knows how their details are used and kept.
- Ask only for what you use. A PPSN is useful when the practice needs it for a claim or a medical card; leave it blank otherwise.
- Keep completed forms with the patient record, under the same retention policy as the rest of the chart.
Open it in the sample practice
The sample practice is the real Ask Brigid on invented patients, open without a sign-up. This document joins its Library with the next sample-practice update; the Library already holds the practice’s templates.
Sources
- The shipped template's field list (Brigid stationery v12), read 24 October 2026
Checked against the sources above on 23 September 2026. Issuers change their forms; check the official page before you rely on a detail here.
In Ask Brigid this paperwork sits beside the diary and the record: The electronic record for private rooms.