Admin Staff – EMR Pro Forms

Administrator Registration Form

Note:

Your IP Address and location details are captured as part of this submission. Your IP Location: 216.73.216.137
You agree for us to hold this information as part of this submission. We require this for security and legal purposes.

Clinic Information

Clinic Name

Clinic Address

Street Address

City

Province

Postal Code

Country

Administrator Information

First

Last

Phone

4 Digit Pin

I consent to have eHealth Solutions Ltd. my submitted information so they can process my registration and, if needed I can request to delete my data on my request under the GDPR guidelines..

I confirm that all provided details are accurate to the best of my knowledge. I take full responsibility for any misrepresented information and acknowledge that providing false information may lead to legal consequences, including potential liability for fraud or identity theft.

I have read and agree to the Terms and Conditions and Privacy Policy