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PACS Application Form

Email Address*

Please provide an email address that is easily accessible to you. In the future, if you forget you password or have to reset your password for some other reason, this is the email address where your new temporary password will be sent.
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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