Thank you for your interest in joining Tully Family Practice. Please fill in the application below and a member of reception will get back in contact with you, if we are in a position to accept you at this time.

Fill in application form online here:

Tully Family Practice Application Form

Name

First Name

Last Name

Address

Date of birth

Sex

Male

Female

Phone Number (Mobile)

Phone number (Landline)

GMS/DVC no if applicable and expiry date

Previous GP name and address

Next of Kin name

Next of Kin relationship

Next of Kin phone number

Health Insurance if applicable

How did you hear about us?

If you become a patient of TFP do you consent to SMS/text message notifications for appointments and results?

Yes

If you become a patient of TFP, you may wish to receive results/reports/certs from us in email form. Please note email is not secure and you will always have the option to collect hard copies from reception. We will only send results/reports/certs in response to an email request from the patient. If you consent to receiving results in this manner please tick here:

Yes I consent

No I do not consent

Other family:

Name & DoB of any other family members wishing to join. Please indicate if any hold GMS/DVC cards. All over 16s must fill in their own form.

Application form also available to download in PDF here.

Email, post or drop off at reception.