eReport Delivery Questionnaire
To ensure ultrasound results are sent automatically to your practice, please complete the e-report questionnaire below. This will ensure doctors receive the results promptly when they are ready. Please contact your IT personnel to assist with any questions you have difficulty with. The form can be saved and be continued at a later date if necessary.
Practice Name:
*
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
example@example.com
Phone Number:
*
-
Area Code
Phone Number
Fax Number:
-
Area Code
Phone Number
Please list all the doctors that wish to receive reports:
*
Rows
Doctors Name
GP/Specialty
Provider number
1
2
3
4
5
6
7
8
9
10
11
12
Are you already using Promedicus.net for downloading results?
*
Please Select
Yes
No
Do you have a Technical Contact for your practice?
Please Select
Yes
No
Technical Contact’s name:
First Name
Last Name
Technical Contact’s email:
Phone Number:
*
-
Area Code
Phone Number
What Operating System does the computer you intend to install our software on use?
Windows Server
2003
Windows 7
Windows 8
Windows 10
Windows 11
Windows Server Version:
Mac OS Version:
(if using Mac)
Do you have a Local Area Network (LAN) in the practice?
Please Select
Yes
No
How many computers on the LAN can access the internet simultaneously?
Please Select
1
2
3
4
5
6
7
What clinical software package do you use?
Yes, I would like to download the software. Please contact me with my username and password. URL for download: http://www.promedicus.com.au/support/support-files
No, I want Promedicus.net support to call my technical contact or practice contact and do a remote install via TeamViewer
TERMS OF ACCEPTANCE OF NOMINATION
I/we, the Practice named above, accept your nomination that l/we be appointed as a registered user of the Promedicus.net Secure Email System. I/We understand that this will require my/our agreement to install the Promedicus.net Client Software on my/our computer. I/we understand that l/we may either accept or reject the installation and acceptance will be on the terms of the "Licence Agreement for Use of the Promedicus.net Secure e-report System by Nominated Recipient”, I/we agree that any person who installs the Promedicus.net Client Software on my/our computer does so as my/our agent on my/our behalf. These terms maybe viewed by accessing our Terms of Use (https://www.promed.com.au/terms-of-use/) or by reading the licence agreement displayed when installing the software.
Signature
*
Name of signatory:
*
Title:
Date
*
-
Day
-
Month
Year
Date
Save
Submit
Should be Empty: