Pre-Registration Form

Do you/applicant intend to register as a GMS or GP visit card (Over 70s, Under 8s or Carers) ?

Yes, however I fully accept it’s not a guarantee and it could be with Dr Philip Adam Dowling (T&C apply)No

*Terms of Registration

Given Dr Agarwal has reached the capacity to take on new patients on his GMS panel, you may wish to register with Dr Philip Dowling. Please be aware that Dr Dowling might move out of current setup and thus your registration might be moved along with him.

LIMITATION ON NUMBERS by HSE
The number of persons whose names may be placed on the list of the practitioner (or, in the case of a practitioner who has agreements with two or more areas within the Health Service Executive, the total of the numbers which may be placed on the lists for those areas) shall not exceed 2,000 save where the Health Service Executive, in exceptional circumstances, after consultation with the Irish Medical Organisation, decide to apply a higher limit. Where a medical practitioner who has entered into an agreement holds or obtains an appointment under the Health Service Executive, the Health Service Executive may specify a limit lower than 2,000 for the number of eligible persons on the list or lists of that practitioner.

Please fill the form multiple times for each member that you wish to register.

I will fill this form separately for each family member.

First Name*

Surname*

Mobile Phone*

Gender assigned at birth*

Address Line One*

Address Line Two*

City*

Eircode* (Without Space)

Email ID*

Date of Birth*

PPS Number*

Next of Kin Name

Relationship to Patient

Do you have private health insurance? YesNo

Name and address of previous GP*

Do you consent to receiving communication from us through email or text message and accept the non-secure and non-reliable nature of those modes of communication?* YesNo

Undertaking*By using this form I agree with the storage and handling of my data by this website or by the practice, in line with GDPR / privacy policy.

I understand that completing this form does not guarantee acceptance to the practice.

It is my responsibility to contact the practice to check registration status if not heard back in 6-8 weeks’ time.

Once accepted I agree to self organise the transfer of medical records from my last GP. Medical Records Transfer Request form

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