Www.blackrockmedicalcentre.ie



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74 Skehard Road, Blackrock, Cork

Tel: 021 489 2996 – Fax: 021 435 7982

blackrockmedicalcentre.ie

Dr Aoibhe O’Driscoll MB, BCh, BAO, BMedSc, DCH, DOWH, MICGP (MCRN 20110)

Dr David Lane MB, BCh, BAO, BMedSc, DCH, DME, MICGP (MCRN 23755)

Dr Racquel O’Halloran MB, BCh, BAO, DCH, DRCOG, MICGP (MCRN 363122)

NAME: ___________________________________ PHONE NO: _______________________

ADDRESS: _______________________________ MEDICAL CARD NO: _______________

E-MAIL: __________________________________ CURRENT GP: ____________________

ADDITIONAL FAMILY MEMBERS:

| |Date of Birth |Medical Card Number |

|Name | | |

| | | |

| | | |

| | | |

| | | |

REASON FOR MOVE: _________________________

BRIEF MEDICAL HISTORY (SIGNIFICANT EVENTS ONLY):

_____________________________________ ___________________________________

_____________________________________ ___________________________________

_____________________________________ ___________________________________

_____________________________________ ___________________________________

CONSENT: 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.

SIGNED: _____________________________ DATE: __________________

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EXPRESSION OF INTEREST FORM TO REGISTER AS A PATIENT

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