Applications will be assessed on an individual basis
Filling out an application form does not guarantee acceptance
If you are accepted as a patient we will use the information below to create your personal medical record
You must fill out the below form for each member of your family you are applying for
Our team will review your application form and contact you with a decision
We will take into account
- Your individual circumstances
- Whether other members of your family are also patients of the practice
- The distance you live from the practice - this will impact the quality of care we are able to provide
- Our current practice size and our capacity to provide high-quality medical care

Name *

First Name

Last Name

Date of Birth (DD/MM/YYYY) *

Gender *

Male

Female

Prefer not to say

Pronouns

he/she/they/them/their

Mobile Number *

Email *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have a medical card or doctor visit card? *

Yes

Medical card number / Doctor visit card number

PPS Number *

Practice and Name of Previous GP *

Why do you wish to change medical practice? *

Please list any medical conditions *

Please list any medications your are taking, the strength and how often you take them *

Name of Next of Kin, phone number and relationship to you *

Please list any surgeries you've had *

Do any conditions run in your family? *

Are you allergic to Penicillin? *

Yes

Did you complete all your childhood vaccinations / immunisations *

Please list any medications your are Allergic to

Do you smoke? *

Yes

Do you drink alcohol? *

Yes

Please list any other family members who also with to join the practice below.

You will need to fill out this form for each of the family members you've listed below

I understand that submitting this form does not guarantee acceptance as a patient *

I agree

I consent to being contacted on the mobile phone number above regarding appointments, test results and, practice updates *

I agree

If accepted as a patient I consent to Tubbercurry Family Practice attaining a copy of my medical record from my previous GP *

I agree

Thank you!

We will review your application and respond to you on the email address you provided.

Your application will be reviewed and assessed by our management team.

This team meets monthly. It may be 4 weeks before you receive a decision.

Practice Details

Address: Tubbercurry Family Practice, Teeling St, Tobercurry, Co. Sligo, F91 PD27

Phone: (071) 918 5373

Healthmail account: tubbercurryfamilypractice.gp@healthmail.ie

For Healthcare professionals with HSE email address only.

(Please note healthmail is a not an open public email and will only allow messages to be sent from registered medical professionals)

Out of hours and emergency Contact Numbers & Addresses

Caredoc: 0818 365399 , Barrack St Primary Care centre, Sligo Town.

Life Threatening Emergencies : Call 999 or 112

National Ambulance Service : Call 999 or 112

Nearest Emergency Departments:

Sligo University Hospital - The Mall, Sligo Town

Mayo University Hospital, Westport Rd, Knockaphunta, Castlebar, Co Mayo.

Minor Inury Units:

Roscommon Minor Injury unit (twists, sprains, cuts, bites, cuts, abscesses, suspected broken bones)

Links , Forms & Practice Policies

Applications & Forms