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Qpacs account setup

Please fill in the following form to be set-up for Qscan's remote image viewing facility, Qpacs.

Practice Name*
Practice Address*
Practice Email Address
Practice Manager*
Telephone Number
Fax Number

Practioner Name 1*		Provider Number 1*
Practioner Name 2		Provider Number 2
Practioner Name 3		Provider Number 3
Practioner Name 4		Provider Number 4
Practioner Name 5		Provider Number 5
Practioner Name 6		Provider Number 6







Submit
* Required