HMMS New User Profile Addition : HMMS Site Only

1
Name of HMMS site* This field is required.Please choose which site you are requesting from
Please Select
Please Select
Connolly Hospital Blanchardstown
Children's Health Ireland
Merlin Park University Hospital
Phoenix Pharmacy
Rotunda Hospital
South Infirmary Victoria University Hospital
St. Vincent's University Hospital
Tallaght University Hospital
University Hospital Galway
CHI Crumlin
2
Name of Requestor* This field is required.Please provide your full name
First Name
Last Name
3
Email of Requestor* This field is required.Email Contact 1
example@example.com
4
Email of HMMS User* This field is required.(To send the HMMS User their username & password)
example@example.com
5
Line Manager / Chief Pharmacist Email* This field is required.User Access must be approved by Line Manager/ Chief Pharmacist
example@example.com
6
Phone Number* This field is required.
Area Code
Phone Number
7
New User Profile Details* This field is required.Please fill in the details of a New User
8
HMMS User Profile* This field is required.Please select HMMS User Profile that describes your role
Please Select
Please Select
System Manager
Chief Pharmacist
Pharmacist
Pharmacy Technician
Procurement
Pharmacy Aide
Pharmacy Admin
Student
Research
Finance
Finance (with Invoice Reconcilliation)
Stock Locator
9
Approval for HMMS User Profile* This field is required.The HMMS User Profile must be agreed with your line manager
Name of Line Manager
Role of Line Manager
Please Select
Please Select
Yes
No
Disclaimer: My Line Manager / Chief Pharmacist are aware and they have approved my user role
10
Additional informationPlease input any additional information or comments to support your request
Huge
Large
Normal
Small
Ok
Ok
11
File AttachmentSubmit documents as required to supplement request
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Confirmation Email Consent* This field is required.A confirmation email will be sent to you once your Jotform is submitted. Please tick the box below to confirm consent
Agree
Should be Empty: