New Practitioner Form

Register Your Details

Please complete this form to be set up as a new doctor within the Qscan Radiology Clinics platform. This will enable you to receive your images, reports, and billing information. Please use details exactly as they are listed on AHPRA https://www.ahpra.gov.au

Note: If you would like to arrange image/report access, please click here for InteleViewer.

InteleConnect/InteleViewer

Practitioner Full Name* *

(Title) (First Name) (Last Name)

Provider Number* *

Gender* *

Registration Specialty* *

Practice Name or Hospital* *

Practice Address* *

(Street Address) (Suburb) (State) (Post Code)

Work Phone Number* *

Mobile Number

Fax Number

(Fax Number, include areas code)

Preferred Report Delivery Method*

Fax

Medical Objects

Healthlink

Please Provide Healthlink EDI* *

Message* *