Patient Registration Form

Please complete all required fields marked with *

Personal Information

Please enter your first name
Please enter your last name
Please enter your date of birth
Please enter a valid PPS number (e.g. 1234567AB) Optional - for Irish residents only
Please enter a valid email address

Contact Information

Please select your country
We'll send a verification code to this number Please enter a valid mobile number
Please enter your address
Please enter your city or town
Please select your county/state
Please enter a valid Eircode (e.g. D02 XY45)

Government Benefits

Must be 8 characters ending in a letter (e.g. 1234567A)

PRSI Checker

I Consent to this practice Collecting and maintaining a record of my PPSN for the purposes of verifying my eligibility for dental benefits and where appropriate and the submission of claims for payment.

Medical Card Checker (optional)

I Consent to this practice Collecting and maintaining a record of my Medical Card for the purposes of verifying my eligibility for dental benefits and where appropriate and the submission of claims for payment.

Current Dental Condition

Medical History

Digital Signature

Please sign below using your mouse or finger

How Did You Hear About Us?

Opt-in: Exclusive Offers & Latest Info (optional)

We'd love to send you exclusive offers and the latest info by email, post, SMS, phone and other Electronic means. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes.

Consent & Terms

🔒Your Privacy Rights (GDPR)

Under the General Data Protection Regulation (GDPR), you have the following rights regarding your personal data:

  • Right of Access: Request a copy of your personal data
  • Right to Rectification: Request correction of inaccurate data
  • Right to Portability: Receive your data in a portable format

Data Collection Notice: When you submit this form, we collect and store your IP address and device information for security, fraud prevention, and verification purposes.

Your data will be securely stored and used solely for dental treatment and practice administration purposes. To exercise any of these rights, please contact the practice directly.

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Patient Registration System v1.0.9