General Registration

Please complete the registration form below.

We will reply to confirm your appointment (if not already scheduled) and answer your questions.

Thanks for booking with us.

"*" indicates required fields

Patient Information

Your name*

First Last

Date of Birth*

Address*

Address line 1 Address line 2 County Country

Preferred Phone*

Email*

Preferred Clinic Location*

Family Doctor / GP*

First Name Last Name

Family Doctor / GP Address*

Address line 1 Address line 2 County Eircode Country

Family Doctor's Phone Number

How did you hear about us?*

Allergies

Do you have any allergies?*

Yes

No

If yes, please describe:

Please describe the main issue or concern you would like to discuss during your consultation.*

Medical History

Do you have a history of easy bruising?*

Yes

No

Do you have nosebleeds with little or no trauma?*

Yes

No

Have you ever had abnormal or prolonged bleeding after a dental procedure?*

Yes

No

Did you have any bleeding problems, or blood loss, since birth?*

Yes

No

Does your family have any history of bleeding problems?*

Yes

No

Do you have any reason to believe that you have low blood pressure or low hemoglobin?*

Yes

No

Have you ever experienced fainting after an injection or medical procedure?*

Yes

No

Do you have a Pacemaker, Cardiac Implant or Cochlear Implant?*

Yes

No

Have you ever been bothered by a tight band on the underside of your penis that causes pain or bleeding during sex?*

Yes

No

Do you have any active medical conditions or significant past medical history?*

Yes

No

If yes, please describe:

Please list any medications you are taking. Enter "none" if none.*

(name/dosage)

Emergency Contact Name*

First Last

Emergency Contact Phone*