HealthlinkOnline Application Form for Dentists

Please complete the form and click Submit. Fields marked with * are required.
If you have any problems please call us on (01) 8287115.

Dental Practice Name:*
Address:*
Eircode / Postcode:* Find eircodes at www.eircode.ie
Phone Number:*
Fax Number:*
Mobile Number:*
Practice Email Address:* Please ensure all Healthlink users in the practice have access to this email account as it will be required for changing password on first login.
 
Dentist & Practice Staff Details
 Person One Details
Name:*
Position:*
Registration Number (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code:* (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 
 Person Two Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Three Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Four Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Five Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Six Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Seven Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Eight Details show additional practice staff details hide practice staff details
Name:
Position:
Registration Number: (Dentist only)
Mother's Maiden Name:* (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 
Hospital Details
Which Hospitals would you like to receive messages from:
All Live Hospitals
All Future Hospitals
Alliance Medical
AMNCH
Bantry
Beaumont
Beacon
Bon Secours, Glasnevin
Cappagh Hospital
CareDoc
Cavan General
Cavan General
Connolly
Cork University Hospital
Crumlin Children's Hospital
DDoc
Ennis General
Euromedic Cork
Euromedic Dundrum
Euromedic Kilkenny
Euromedic Meath PCC
Euromedic Northwood
Limerick Regional
Letterkenny General
Louth County
KDOC
Kerry General
Mallow General
Mater
Mater Private
Mayo General
Mercy University Hospital
Merlin Park
Monaghan County
Mullingar
Naas
NCSS
NorthEast Doc
NVRL
Our Lady of Lourdes, Drogheda
Our Lady's Hospital, Navan
Portlaoise
Portiuncula
Roscommon County
Rotunda
ShannonDoc
Sligo Regional
SouthDoc
South Infirmary
South Tipperary General
St. Columcille's
St. James's
St. John's, Limerick
St. John of God's
St. Joseph's, Nenagh
St. Luke's, Kilkenny
St. Mary's, Phoenix Park
St. Michael's, Dun Laoghaire
St. Vincent's
St. Vincent's Private
Temple St. Children's Hospital
Tullamore
UCHG
Waterford Regional
Wexford General
WestDoc
 
Practice Computerisation
Practice Management System:
Version Number of PMS:
 
Form Completed by:
Form Date: Cal
   
Please confirm you have read and accepted the terms and conditions by ticking the box: