NSBD - PACS Application

Practice name *

Work street address *

City *

State *

Postcode *

Work phone *

Further Information

First Name *

Last Name *

Email *

Provider No

AHPRA registration number *eg MED000XXXXXXX, CHI000XXXXXXX, PH000XXXXXXX

Add another referrer

First Name *

Last Name *

Email *

Provider No

AHPRA registration number *e.g. GP, physiotherapist, specialist type, etc

Add another referrer

First Name *

Last Name *

Email *

Provider No

AHPRA registration number *e.g. GP, physiotherapist, specialist type, etc

Add another referrer

First Name *

Last Name *

Email *

Provider no

AHPRA registration number *

Add another referrer

First Name *

Last Name *

Email *

Provider no

AHPRA registration number *e.g. GP, physiotherapist, specialist type, etc

By ticking this box you are agreeing to the following terms and conditions:

To comply with the confidentiality and external access terms and conditions
My data being collected and stored as per PRP's privacy policy
To access the PRP Portal/InteleViewer™ only in the course of your work as a treating health professional and not for any other purpose
To keep the contents of PRP PACS confidential and not disclose the contents of PRP PACS to any person

*

Date Stamp