Hse Medical Card And Gp Visit Card Application Form Page 11
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12Medical Card and GP Visit Card Form MC1 11
Part 6 – Doctor of choice
Doctor’s name:
Doctor’s practice address:
Will your dependants (if you have
Yes
No
any) attend this doctor?
Part 6A – Doctor’s acceptance
Ask your doctor to complete this section of the form
I agree to provide medical services to this applicant and his or her dependants, if any.
Signature of doctor:
GMS STAMP HERE:
GMS no.
Date:
D D M M Y Y Y
Y
If your spouse or partner requires a different doctor of choice, please complete Part 7 and ask their
doctor to complete Part 7A.
Part 7 – Spouse’s or partner’s doctor of choice
Doctor’s name:
Doctor’s practice address:
Will your dependants (if you have
Yes
No
any) attend this doctor?
Part 7A – Doctor’s acceptance (for spouse or partner)
Ask your spouse’s or partner’s doctor to complete this section of the form
I agree to provide medical services to this applicant and his or her dependants, if any.
Signature of doctor:
GMS STAMP HERE:
GMS no.
Date:
D D M M Y Y Y
Y
Complete Checklist on next page.
MC1 May 2015
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