ED

Emergency Department

Pre-Registration

Your details

The Personal, Current address, Contact and GP details sections are required. The rest help us care for you better but can be skipped.

First name

Last name

Date of birth

Sex

Address line 1

Address line 2 (optional)

City / town

County (optional)

Eircode (optional)

Mobile phone

Email (optional)

Home address

Only if different from the address above.

Your General Practitioner's contact details.

GP name

GP practice / clinic

GP phone

GP address

Someone we can contact on your behalf.

First name

Surname

Relationship

Contact number

Address line 1

Address line 2

Town / city

County

Eircode

I confirm the information above is accurate and consent to it being shared with hospital staff for my Emergency Department visit.