HMMS Drug File EAN and GTIN 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* This field is required.Email Contact 1
example@example.com
4
Email* This field is required.Email Contact 2 (if Contact 1 is unavailable)
example@example.com
5
Phone Number* This field is required.
Area Code
Phone Number
6
Details of HMMS NDF Product* This field is required.Please fill out all fields. We need the information to ensure accurate EAN/GTIN association
7
Is this Medication Unlicensed?* This field is required.
Please Select
Please Select
Yes
No
8
Example of Product ImagePlease ensure you attach a clear, unobstructed and non-blurry image
9
Product ImagePlease ensure you attach a clear, unobstructed and non-blurry image
10
Example of EAN barcodePlease ensure you attach a clear, unobstructed and non-blurry image
11
EAN Image AttachmentSubmit image of EAN barcode
12
Example of GTIN barcodePlease ensure you attach a clear, unobstructed and non-blurry image
13
GTIN Image AttachmentSubmit image of GTIN barcode (ensure to include PC Code)
14
File AttachmentSubmit documents and SPCs as required to supplement request
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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15
Additional informationPlease input any additional information or comments to support your request
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Ok
Ok
16
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
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