Download the Irish version of the form
You can also LoCall 0818 22 44 78 to order one.
Send the completed application form to:
LTI Client Registration Unit
PO Box 12962
What to include in your application
Your doctor or consultant will need to sign the form and provide a medical report.
On the form, they will list any:
- long-term illness conditions you have
- medication and appliances you need to treat your condition
You will need to provide the following personal information:
- Full name
- PPS number
Incomplete applications take longer to process. This is because we may need to contact you for more information.