Become A Patient – Medical QuestionnaireMedical Cards are not accepted at present. To become a patient please complete this form (in English only) Step 1/4: Leave this field blank Medical QuestionnairePlease complete this form in English only First Name Last Name Email Address Address 1 Address 2 (optional) Eircode (optional) Mobile Number Home Number (optional) Work Number (optional) Date Of Birth *For mobile devices, tap the year on top left of popup calendar to select DOB year PPS No: Are you Allergic to Penicillin? Yes No PRSI Checker I Consent to this practice Collecting and maintaining a record of my PPSN for the purposes of verifying my eligibility for benefits and where appropriate and the submission of claims for payment. I Consent Do You Have Private Health Insurance? Yes No Private Health Insurance Provider Insurance Policy Number Review The List Below & Tick Any Boxes That Are Relevant To You Arthritis Pacemaker / heart surgey Hayfever, eczema, allergies Bronchitis, asthma, chest Fainting, giddiness, epilepsy Diabetes / family member Bruise easily after extraction Excessive Bleeder / family Carry a warning card Antibiotic Cover needed Pregnant Rheumatic Fever / cholera Jaundice Liver Disease Kidney Disease Taken steroids in last 2 years Hepatitis Smoker Are You HIV Positive Heart Murmur / heart problem Angina / Blood Pressure Heart attack / Stroke Blood refused Joint Replacement Oral Contraceptive Pill / HRT Had any blood test, Innoculations Osteoporosis / History in family Blood Clot Reaction to LA / GA Have You Been Hospitalised (please give details) (optional) Have You Had Any Serious Illnesses (please give details) (optional) Additional Medical Information (optional) How Did You Hear About HearMed Medical Centre? Family Friend Google Website Email Newspaper Other Opt-in: Exclusive Offers & Latest Info (optional) We’d love to send you exclusive offers and the latest info by email, post, SMS, phone and other Electronic means. We’ll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes. SMS Phone Email Post I agree to the storage and handling of my data by HearMed Medical Centre I agree I agree to the Terms & Conditions I agree Continue
