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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.

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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.

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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 are accepted as a new patient and have a chronic medical condition or take regular medications, we request that you arrange a registration consultation with a GP.

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​Please note that adults must complete their own separate form to register, however children can be included on a parent's application.

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

Do you have a medical card/doctor visit card?
Are you allergic to penicillin?
Are you allergic to any medications?
Do you smoke?
Do you drink?
Are you getting regular mammograms?

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?

If you have a medical card/DVC with another GP you will need to sign a transfer of medical card. Please enquire at reception re same.

Declaration and Consent

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I am applying to be a new patient of Haven Medical Practice.

I declare that the information I have given is correct to the best of my knowledge.

Should there be any change in the above, I will contact Haven Medical Practice.

I agree that it may be necessary to discuss aspects of my medication or medical history with a pharmacist or health care professional as appropriate to facilitate my care.

I give permission for Haven Medical Practice to share data e.g contact number, when necessary, with hospitals, pharmacies etc.

I give permission to Haven Medical Practice to contact me via phone, text message and email.

I give consent to register for Haven Medical Practice’s online prescription ordering system

  • I give permission to Haven Medical Practice for my data to be stored and used for the purpose of online prescription.

  • I consent to having this website store my submitted information so they can respond to my inquiry

 

If it applies, I confirm that I am the parent or legal guardian of the named applicant, and I give consent on their behalf.  

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.

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