Free template · PDF
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 is on the form
- 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.
Less paperwork to fill in at all.
Ask Brigid sends digital intake forms to the patient before the visit, and keeps what comes back in the record. The electronic record for private rooms.
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