Applying for Membership - Medical & Dental Consultants Association

Membership Category
Membership Category*
Please describe the category that best describes you: *
Step 1 - Personal Details
First Name*
Middle Name
Last Name*
Title*
Date of Birth*
DD slash MM slash YYYY
Home Address
Address Line 1 Address Line 2 City / Town County Eircode (optional)
Contact Details – Personal
We will not share your personal details with any third party. They are for administrative purposes only, to be used in membership correspondence with you.
Email*
This is the email address you will use to access your online MDCA account.
Mobile*
Telephone

Step 2 - Work Details
These are the details that will appear in your public profile on the MDCA website. You will be able to edit them whenever you wish.
Work Address
Address Line 1 Address Line 2 City / Town County Eircode (optional)
Contact Details – Work
Work Telephone
Work Fax
Work Email
Work Mobile
Website

Step 3 - Professional Details
Medical / Dental Council Number*
Choose One*
- Specialist Medical Register
- Specialist Dental Register
- No Specialist Register
Private Practice*
- Full-time
- Part-time
Private Hospital(s)*
List the private hospitals in which you work.
Public Work
- Permanent Public Contract
- Locum
Public Contract
Type:
Public Hospital(s)
List the public hospitals in which you work.
Specialty*
Sub-Specialty / Division

Step 3 - Data Consent
Any personal data you provide in this form will be treated in the strictest of confidence and in full compliance with GDPR legislation. When you submit this form, the identifying information you have specified (name, email, telephone etc.) will be held by us for the purpose of communicating with you about your MDCA membership. If you are happy for your data to be stored and used in this way, please tick the box below.
Consent*
I consent to the MDCA storing and using my personal data for the purpose of communicating with me about my MDCA membership.*
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Membership Category