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Request to Register as a Patient

Join Our Waiting List

Thank you for your interest in becoming a patient at Galway Primary Care.

Please complete the form below, and we’ll contact you when we have availability.

Many thanks.

GP Care

Full Name

Date of Birth

Address

Occupation

Email

Phone

Medical Card/Doctor Visit Card Y/N *

Yes

No

Current Medical Conditions

Current Medications

Current GP Name

Current GP Practice

Additional information

Reason for request *

New to area

Services Provided

Availability of own GP

Change in clinic preference

How Did You Hear About Us?

Friend/Family

Google Search

Social Media

Advertisement

Other

We value your privacy. Your information will only be used for the purpose of managing our waiting list and will not be shared with third parties.

After submission, you will receive an email acknowledging your application.

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