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Mr. Jack Kelly
MB, FRCSI, MD,
FRCS(Plast)

Suite 2
Galway Clinic
Doughiska, Co. Galway

Tel. 091-720011
Fax: 091-720014

Secretary: Teresa O'Connor

Email:
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Department of Plastic Surgery
University Hospital Galway
Newcastle Road
Galway
E-Referral

The form below is for Doctors only. If you have a general query, please consult your GP directly.

Patient Name
Patient Address
Patient Phone Number
Patient Email
Cosmetic Diagnosis
Skin Diagnosis
Hand Diagnosis
Description of Problem
Urgency
Medical Conditions
Other Medical Problems
Medications 1
Medications 2
Other Medications
Allergies
Smoker
Referring Doctor
Doctor Phone Number
Doctor Email Address
Additional Information
 
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