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

Would you like to receive an automatic email notification when images are available in PACS for your patients?

Click on the checkbox to sign the document*

Signature- Please type your full name in the field below*

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