In order to provide for your care we need to collect and keep information about you and your health in your personal medical record. Please complete the following form carefully. The information will be used to create your personal medical record on the practice computer.

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Our practices are consistent with Medical Council guidelines and the privacy principles of the Data Protection Acts. For further details please see our Privacy Policy.

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Submitting the form does not guarantee acceptance to the practice. A member of our team will contact you as soon as possible if we have any space on our patient list. 

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If you would prefer to submit the form in writing there are copies available in the practice to pick up.