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Registration form
Welcome to Kinsealy Medical Centre
Please fill out our new patient registration form as below, a member of our clinic will be in touch with you shortly.
Registration form
Name
Home address
Date of birth
Email
PPS number
Type of patient
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Medical card/ DVC/ under 6 card number (if any)
Mobile Number
Current Medications ( + any drug allergies or previous allergies to vaccines)
Medical/ Surgical History
Previous GP
How did you hear about us?
Submit
Thanks for submitting your registration form to Kinsealy Medical Centre
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