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Patient Enquiry

New Patient Enquiry

What type of appointment do you require?(Required)
Do you hold a valid Irish Medical Card or Doctor Visit card?(Required)
Name(Required)
* If you do not speak English, please bring someone who can translate for you during your appointment.
Date of birth (dd/mm/yyyy)(Required)
Address(Required)
All information provided is handled with utmost confidentiality and processed according to GDPR (General Data Protection Regulation) and The Data Protection Act 2018. Occasionally, we email updates about clinic operations, like changes in hours or new services. Your details will never be shared with third parties for marketing purposes. Submitting this form does not imply registration as a patient of Berkeley Clinic.