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PACS Application Form

Email Address*
Practitioner Name*
First Last
Professional College ID Number*
Practitioner Type*
Specialty*
Practice Address Information*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone Number*
Fax*
Physician Backline Phone Number
Optional - If you provide additional information, our Radiologists can contact you with urgent results. Choose all that apply:
- Pager
- Cell Number
- Text Message
- Email
Pager
Cell Number
Text Message
Would you like to receive an automatic email notification when images are available in PACS for your patients?
- Yes
- No
Please read the Password Acknowledgement and System Use Agreement
Click on the checkbox to sign the document*
- I agree
Signature- Please type your full name in the field below*
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