PACS Application Form

Email Address*

*** Attention to any MOA's completing this form... Please provide an email address that is easily accessible to the clinician who will be using this account. In the future, if the password is forgotten or needs to be reset for some other reason, this is the email address where the password reset email message goes. If your clinician tries to reset their password and does not have easy access to this email address then they will not be able to automatically reset their password and will need to contact the clinic. If you would like to set up a second account for MOA access to images for your clinician that is easily done by submitting a second PACS application form.***

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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