Register your Interest
Please complete this short form. A member of the Care-Connect team will be in touch.
Name
*
First Name
Last Name
Phone Number
*
-
Prefix
Phone Number
Email
*
name@example.com
Date of Birth
*
-
Day
-
Month
Year
Irish Life Health Member No
*
This will be 7 numerical numbers
Irish Life Health Policy Number
*
Eg VIVG123456
Please let us know which Care Programmes you are interested in?
Heart Failure
Respiratory
Sleep Apnoea
If you wish to apply to participate in the Sleep Apnoea Programme you will require a referral letter from your GP. Please upload this letter here and our team will be in touch to discuss the programme further with you.
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Enable Sleep Apnoea Payment
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Sleep Apnoea Test
€
550
If you would like Care-Connect to contact your GP to discuss your participation in the Care-Connect programme, please enter their contact details below:
Name of your GP
First Name
Last Name
GP Phone Number
-
Area Code
Phone Number
GP Address
Street Address
Street Address Line 2
City
County
Eircode
Do you wish to be contacted by Care-Connect in the future about Care-Connect news and new care programmes?
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I have read and agree with the terms of the Data Privacy Policy.
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Yes
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