Allergy Cork | Paediatric Allergy and pulmonology

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Our clinic
Our Services
Our team
FAQ
Fees
Contact

Suite 1.1
Consultants Private Clinic
Cork University Hospital
Bishopstown Rd
Wilton
Cork
T12 CK2X

Please note: self- or GP referral needed to book

Appointments
083 347 6443
Tue & Thu 9.30am – 1pm

Clinic
083 204 1940
Mon 8.30 am – 5 pm

info@allergycork.ie

FOR HEALTHCARE PROFESSIONALS ONLY:
juan.trujillowurttele@healthmail.ie

Please self-refer (request an appointment) here

Initial Paediatric Allergy Consultation

Child's name *

DOB *

Address *

GP name and address *

Parent/guardian’s name *

Parent/guardian’s contact number *

Parent/guardian’s email address *

Please describe your child’s current compliant

Does your child suffer from:

Hayfever
Eczema
Asthma

permission *

Yes, I give permission to store and process my data

permission (copy) *

I give permission to use the email address I provided on this self-referral to send medical information about me/my child

Adult Allergy Appointment with Specialist

Name *

DOB *

Address *

Contact telephone number *

Email *

GP name & address *

Please tell us what the current problem is:

Checkboxes *

Yes, I give permission to store and process my data

Checkboxes (copy) *

I give permission to Allergy Cork to use the email address I provided on this self-referral to send me personal medical information

Hydrogen Breath Testing

For myself

Name *

DOB *

Address *

Contact telephone number *

Email *

GP name & address *

Please tell us what the current problem is:

Checkboxes *

Yes, I give permission to store and process my data

Checkboxes (copy) *

I give permission to Allergy Cork to use the email address I provided on this self-referral to send me personal medical information

For my child

Child's name *

DOB *

Address *

GP name & address *

Parent/guardian’s name, contact telephone number & email *

Please tell us what the current problem is:

Yes, I give permission to store and process my data

Field #13 (copy) *

I give permission to use the email address I provided on this self-referral to send medical information about me/my child

Paediatric Dietetic Self-Referral

Child's name *

DOB *

Address *

GP name and address *

Parent/guardian’s name *

Parent/guardian’s contact number *

Parent/guardian’s email address *

Please describe your child’s current compliant

permission *

Yes, I give permission to store and process my data

permission (copy) *

I give permission to use the email address I provided on this self-referral to send medical information about me/my child

permission (copy) (copy) *

I acknowledge that this dietetic appointment does not involve management of a general paediatrician

Adult Dietetic Self-Referral

Full Name *

DOB *

Address *

GP name & address *

Contact number *

Email *

Please describe your current compliant:

Checkboxes *

I give permission to store and process my data

Checkboxes (copy) *

I give permission to Allergy Cork to use the email address I provided on this self-referral to send me personal medical information

Our clinic
Our services
Our team
FAQ
Fees
Contact Us
Privacy Policy

Designed by Efraín Bernal

© Allergy Cork

Neve | Powered by WordPress

Our clinic
Our services
Our team
FAQ
Fees
Contact Us
Privacy Policy

Designed by Efraín Bernal

© Allergy Cork

Neve | Powered by WordPress

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