Patient Registration Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Please select your clinic of choice * Liffey Street Pembroke Road Coolock First Name * Middle Name Surname * Date of Birth * Address * Eircode * Phone Number * Occupation E-mail * How did you hear about us? * [Please Choose] Friend Advertisement GP Family Member Student Union Health Board Other For the purposes of CERVICAL CHECK and other HSE Services: PPSN * CPSID No. (Found on CervicalCheck letter) Mother's Maiden Name Are you a MEDICAL CARD holder? (Valid in our Coolock Centre ONLY but can be used as an identifier for other services in the Dublin Well Woman Clinics) No Yes Medical Card No. Expiry Date Are you a STUDENT? No Yes Student Card No. Expiry Date Consent I consent to receiving emails for purposes of medical services (such as test results). * No Yes I consent to receive SMS text messages for appointment reminders. * No Yes I consent to the information I have provided to the Dublin Well Woman Centre, being used in order to carry out its various functions and services, including scheduling appointments, ordering tests, hospital referrals, sending correspondence, accounting and reporting requirements for HSE funded services and administering our annual Patient Satisfaction survey. (Read-only policies can be requested from reception or can be viewed in the patient hub at www.wellwomancentre.ie) I have read and understand the nature of the data which is collected by the Dublin Well Woman Centre, the purposes for which the data may be used, the persons to whom data may be disclosed and I understand my rights as prescribed under the General Data Protection Regulation in relation to my personal data. I consent to providing The Dublin Well Woman with the above information without my signature. * Your signature can be provided on arrival at the destination clinic when we resume face-to-face consultations.