Joining the Practice

The Practice welcomes new patients. Please note our books may be closed from time to time depending on patient numbers. If you are interested in registering with us, submit the Expression of Interest form below.  New applications are reviewed once a month so it may be a few weeks before we revert.

Fill in the form below or download it here.

Name *

First

Last

Phone *

Address *

Date of Birth *

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Email *

Medical Card or GP Visit Card *

Current GP *

Reason for Move *

Brief Medical History (Significant Events Only) *

Additional Family Members

Name

Date of Birth

Medical Card or GP Visit Card

Name

Date of Birth

Medical Card or GP Visit Card

Name

Date of Birth

Medical Card or GP Visit Card

Name

Date of Birth

Medical Card or GP Visit Card

GDPR Agreement *

• I consent to my details as stated above being held by Blackrock Medical Centre for a period of no longer than one year and that I may be contacted by Blackrock Medical Centre for the purposes of considering my interest in becoming a registered patient.

Signature

Clear Signature

Date

Submit