New Registration – Healthchange Ireland Registration

Medical professional

Are you a registered medical professional?(Required)

No

Yes

Each clinic registered on Healthxchange Ireland website must have a medical professional (Doctor, Dentist, Nurse)

Personal Details

Name(Required)

First name Surname

Email Address(Required)

Email Address Confirm Email Address

Phone number(Required)

Please ensure you enter a valid phone number, initial 0 should be dropped

Medical Professional Details

Profession(Required)

Registration no.(Required)

Photo ID(Required)

Max. file size: 35 MB.

This can be: drivers license or passport

Salutation

Maiden name

Business Details

Company type(Required)

Company/clinic name(Required)

Other company type

Company Registration No.(Required)

VAT Registration No.

Invoice/billing address

Billing Address(Required)

Address Line 1 Address Line 2 City Eircode

County(Required)

Country(Required)

Phone number(Required)

Please ensure you enter a valid phone number, initial 0 should be dropped

Shipping locations

Billing address is the same as shipping address?

Recipient name (1)(Required)

First Last

Shipping address (1)(Required)

Address line 1 Address line 2 City Postcode

County (1)(Required)

Country (1)(Required)

Location phone number (1)(Required)

Please ensure you enter a valid phone number, initial 0 should be dropped

Add second Shipping Location

No

Yes

Recipient name (2)

First Last

Shipping address (2)

Address line 1 Address line 2 City Postcode

County (2)(Required)

Country (2)(Required)

Location phone number (2)(Required)

Please ensure you enter a valid phone number, initial 0 should be dropped

Add third Shipping Location

No

Yes

Recipient name (3)

First Last

Shipping address (3)

Address line 1 Address line 2 City Postcode

County (3)(Required)

Country (3)(Required)

Location phone number (3)(Required)

Please ensure you enter a valid phone number, initial 0 should be dropped

Additional users

Do you require additional users?

User role (1)

Additional user name (1)

First Last

Additional user email (1)

Enter Email Confirm Email

Add a second user

No

Yes

User role (2)

Additional user name (2)

First Last

Additional user email (2)

Enter Email Confirm Email

Add a third user

No

Yes

User role (3)

Additional user name (3)

First Last

Additional user email (3)

Enter Email Confirm Email

Consent

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