Payment Form – Kildare Medical Centre

Patient Name *

Date Of Birth *

Email *

Consent *

I give consent to the above email address being stored in my patient chart and can be used to contact me if the surgery has a query regarding my prescription or for future correspondence.
I DO NOT give consent to KMCGP to use my email address for future correspondence.

(Chose one)

Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PAYMENT SECTION

Please Note: An administrator will email you a receipt on the next working day. NOTE: Payments are handled by Stripe payment gateway, Kildare Medical Centre do not hold card details of customers.

Amount Of Payment *

Total Amount

0,00 €

Credit Card Details *

Card

Name on Card

PAYMENT SECTION

@2021 Kildare Medical Centre