GP REFERRAL FORM

GP Referral Form

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PATIENT DETAILS

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Please complete all fields and Submit it when complete

First Name

Last Name

Address

Phone Number

Date of Birth

Does the patient hold private health insurance?

Yes

Preferred appointment location?

Beacon Sandyford

Beacon Drogheda

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Please note only skin lesions and hand surgery consults can be seen at our Drogheda location.

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GP Details

Name & IMC number

Practice address

Telephone

Fax Number

Preferred contact method

Post

Fax

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Referral details

Reason for referral/ expected outcome

Symptoms & duration

Past medical/ surgical history

Current medications

Is the patient on any anticoagulants and can same be discontinued if required?

Allergies/ adverse medical events

Relevant social history

Does the patient smoke or use any nicotine replacement products?

Relevant social history

Any other relevant information

GP signature

CONTACT

Call Us

Dublin

Phone: 01-5553777

Fax: 01-5350884

Email:
General enquiries:
office@fitzgeraldplasticsurgery.ie

GP referrals only:

eilisfitzgerald@beaconclinic.ie

Beacon Hospital internal mail: fitzgerald.plasticsurgery@beaconhospital.ie

Privacy Statement

ADDRESS

Ms Éilís Fitzgerald,

Consultant Plastic, Reconstructive & Aesthetic Surgeon

Beacon Consultants Clinic,

Suite 6, Bracken Road,

Sandyford, Dublin 18,
D18 E7P4

Clinic appointments available

8:00 am - 4.30 pm, Monday to Friday

TELEPHONE LINE HOURS

Mon - Thu: 9:00 am - 3:00 pm
Friday: 9:00 am - 12:00 pm
Sat - Sun: Closed

CONTACT

Dublin

Phone: 01-5553777

Fax: 01-5350884

Email:General enquiries:office@fitzgeraldplasticsurgery.ie

GP referrals only:

eilisfitzgerald@beaconclinic.ie

ADDRESS

Ms Éilís Fitzgerald,

Consultant Plastic, Reconstructive & Aesthetic Surgeon

Beacon Consultants Clinic,

Suite 6, Bracken Road,

Sandyford, Dublin 18,D18 E7P4

Clinic appointments available

8:00 am - 4.30 pm, Monday to Friday

TELEPHONE LINE HOURS

Email:
General enquiries:
office@fitzgeraldplasticsurgery.ie

Sandyford, Dublin 18,
D18 E7P4