New User Request

First Name

Last Name

Preferred Name

if different to above

Contact Number

HPI CPN

if known

Registration Number

What do you need ERMS for?

select all that apply

Sending referralsReceiving referralsTriage

Workplace Name

Department/Team

Workplace Address

Is this workplace already using ERMS?

If you need to be connected in with more than one workplace, please let us know in the comments box below.

Yes (Please submit your request and a representative will be in touch once our setup is completed)No (Your request will be passed onto our ERMS Support team, they will be in touch to assist with getting you and your organisation setup with ERMS)

Additional Questions/Comments

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