Appointment Request form

Use this webform to request an appointment on a campus convenient to you.

Have you registered with the Student Health Centre before?

Yes

To assist with your care, we at the DCU Student Health Centre (a unit of Dublin City University) need to collect personal data, including sensitive personal data about you. This information will form part of your record with us and will include details of your health, treatments and any other services that you intend to, or have availed of here, e.g. phlebotomy, vaccinations, dressings, ear syringing, results or any the tests/investigations/screens. In order to provide you with some services, DCU may engage with external partners outside our service (e.g. Mater Hospital for phlebotomy/blood tests). Medical records are strictly private and confidential and do not form part of your degree. You have certain rights under data protection law including the rights of access to a copy of your personal information, right of rectification/correction or erasure of personal data relating to you, or the restriction of processing, the right to data portability and the right to object to processing of your personal data. These rights are available where the applicable criteria are met, and subject to certain exceptions under data protection law. (For example, it may not be possible to comply with a request to erase all data where the Student Health Centre has a legal obligation to retain records,where it is necessary and proportionate to keep such data for the purposes of defending prospective legal claims and/or protect the vital interests of a data subject,or where we otherwise have compelling legitimate grounds to retain this information/records in accordance with DCU’s statutory functions). To exercise any of these rights, please contact healthservices@dcu.ie in the first instance so that we can resolve any issues arising. DCU’s Data Protection Unit can be contacted by email at: data.protection@dcu.ie or by phone at: 01 7005118 /7008257. If you are not satisfied with DCU’s response to any queries you may have in relation to how your personal data is processed by DCU, you have the right to complain to the Data Protection Commission: www.dataprotection.ie. To obtain further information about DCU Privacy Policy please visit: https://www.dcu.ie/sites/default/files/info/25-data privacy v3.1pdf Data Protection Consent Please ensure that you have fully understood this form before signing. If you have any questions, please ask a member of staff. I confirm that I have read and understood the above Data Protection Notice. I consent to my personal data being processed by the DCU Student Health Centre as described. I understand that the law provides that in certain instances personal health information can be disclosed e.g. in the case of some infectious diseases. I understand that any information given to a third party, on or off campus will only be released with my express consent. I understand that I can withdraw consent for processing of my personal data at any time. I understand that my personal data will be stored securely for eight years. I freely consent for the DCU Student Health Centre to process my personal data, including, special categories of personal data (e.g. health) for the purpose of my ongoing healthcare treatment in DCU.

Yes, I consent to the Data protection notice

No I do not consent to the Data protection notice

On which campus would you like your appointment

Glasnevin Campus

St.Patricks Campus

Your Name

Your DCU Email address

non DCU email addresses will be ignored

Phone

Term Address while at college

EIRCODE

Name

Your Name

Name

Your Name

Date of Birth DD-MM-YYYY

Your Date of Birth in DD-MM-YYYY Format

Address Line 1

Address Line 2

Address Line 1

Eircode

Student Number

Your Student number

DCU Email Address

Please enter your DCU email address

Mobile Phone Number

Your telephone number

Student Number

Please enter your current DCU Student Number

Gender

Your Gender and chosen pronouns

Next of Kin

Full Name ,Contact telephone Number , Relationship to you, location

DCU Course Name and Code

Course Name and Code

Doctor outside of DCU

Doctors name : Name & Location of Practice :

Signed By : Your Name & Date :

Student Signature

Sign above

Blood Test Assessment

Questions	Yes Yes	No No
Did the GP in the Student Health Centre order the bloods?	Yes Yes	No No
Did an external Consultant / Specialist order the bloods? Please use the upload option below to upload a copy (image / file) of the bloods required by your Consultant / Specialist	Yes Yes	No No
Did your family / Local GP order the bloods? Please use the upload option below to upload a copy (image / file) of the bloods required by your GP	Yes Yes	No No

Blood Request Form Upload

Please upload a copy of your Blood request letter / form from your Consultant / Specialist / Family GP.

Upload requirements

Contraceptive Pill Assessment

Are you already taking contraceptives OR Do you want to start a contraceptive

I am already taking contraceptives

I want to start taking contraceptives

What Contraceptive are you currently taking?

How many of your current pills / patches have you left?

You are aware the DCU Student Health Centre does not provide free contraceptive services as we do not have the required contracts in place with the HSE. You will be charged €20 for this appointment.

Yes

Medication Assessment

What Medication would you like to have renewed?

Who originally prescribed this medication?

DCU Doctor

Family / Local GP

Consultant / Specialist

When will you run out of your medication?

If an external doctor prescribed this medication and you have not already done so, please provide a copy of the Prescription from the Consultant / Specialist / GP who charted your medication.

Upload requirements

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions..