New User - Parallel ID Request Form

CPH New Parallels ID Request Form
Hovering the mouse cursor over any field will display more information about the information required.
Practice*
Staff Member*

First NameLast Name
Staff Member Role*
(e.g., Nurse, Provider, IT Staff, etc)
A randomly generated password consisting of uppercase and lowercase letters, numbers, and symbols will be generated for this account. The requirements for the password are listed below and ALL criteria must be met.
- Must not contain any form of the user's name or login name
- Minimum of 8 characters
- Must contain at least one uppercase letter (A, B, C...)
- Must contain at least one lowercase letter (a, b, c...)
- Must contain at least one number (1, 2, 3...)
- Must contain at least one symbol (!, @, #...)
EMREMR ManagerPMDentrix
EMREMR ManagerPMDentrixEClinicalWorks
YesNo
Sunday Logon Hours
Monday Logon Hours*
Tuesday Logon Hours*
Wednesday Logon Hours*
Thursday Logon Hours*
Friday Logon Hours*
Saturday Logon Hours*
NoYes
Comments
Name of User Completing This Form*

First NameLast Name
Email Address of User Completing This Form*
example@example.com
Phone Number of User Completing This Form*
Format: (000) 000-0000.
Enter the message as it's shown*
Please note that your request will be forwarded to the CPH HelpDesk and will be responded to by the first available support staff. Please allow up to five (5) business days for your request to be completed.
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CPH New Parallels ID Request Form