Appointments – Athenry Surgery

Please note:
– This form is for NON-URGENT appointments for at least 4 days in advance.
– For more urgent requests please call our surgery.
– You must be a current patient of The Surgery Athenry to use this form.

Name

Contact Number

Date of Birth (DD/MM/YYYY)

Appointment Type (please select)

If your appointment is for a Cervical Smear please include your CSP ID no. below:

Preferred Doctor/Nurse

Preferred Date

Preferred Time (am or pm)
ampmeither

You should not attend your appointment if you have Covid 19 symptoms. Inform us at least 1 hour prior by phone if you need to reschedule.
Please tick here to confirm you will comply with this request.

We will confirm your appointment by text message only.
Please tick here to give permission.