New patient registration form
Riverside Family Clinic
Date: 12 October 2027
1. About you
Full name: Aisha Karimi
Date of birth: 14 June 1988
Sex: Female
Address:
42 Willow Road, Dublin, D06 AB34, Ireland
Phone: +353 1 555 0142
Email: aisha.karimi@example.com
How we may contact you: Text message or phone call. No voicemail with details.
Health insurance or ID number: Policy 123456789
Previous doctor or practice: Dr. S. Murphy, Westside Clinic
2. Emergency contact
Omar Karimi, brother, +353 1 555 0188
Information shared with this person: Yes
3. Your health
Conditions and past operations:
Asthma since childhood
Appendix removed in 2010
Medicines you take now:
Salbutamol inhaler, as needed
Vitamin D 1,000 IU daily
Allergies and reactions:
Penicillin: rash
No food allergies
Serious illness in close family:
Father: heart disease at 60
Lifestyle and other facts:
Does not smoke. Occasional alcohol.
4. Today's visit
A routine check and a repeat prescription for my inhaler.
5. Needs
I prefer an Arabic interpreter for long visits. I use a wheelchair.
6. How we use your information
Riverside Family Clinic keeps this information in your health record to care for you. It is shared only with people who need it for your care, or where the law requires. You can ask to see your record, to correct it and to ask questions about how we use it. Ask the front desk for our privacy notice.
7. Confirmation
I confirm that what I have written is true as far as I know, and I will tell the practice if it changes.
Name: Aisha Karimi
Signature: ______________________ Date: 12 October 2027