Service Application Form ~ Australia

Subscribers Details

Please complete the application form below. (Required fields marked with *)

Practice Name *
Practice Street Address *
Your software pack will be
sent to this address
Suburb *
City *
State *
Country *
Post Code *
Postal Address
Only complete postal address if
different to street address
Suburb
City
State
Country
Post Code
Practice Telephone *    e.g. +61 2 12345678
Practice Fax *
Practice Email *
Contact Names
Practice Primary Contact *
Practice IT Contact
Practice IT Company
Practice IT Contact Telephone
    e.g. +61 2 12345678
Practice IT Contact Email
Practice IT Company Address
(if known)

Healthcare Providers
Please enter the names and provider numbers of the Healthcare Providers at your practice

Name e.g. Dr John Smith
Provider Number

Practice Type *
Please tell us what type of practice or service you provide.

Other

Clinical Software *
Which of the following Clinical Software Systems does your practice use?

Other   

Site Support *
Please select which operating system you will be using.

Other   

Services

Service(s) Applied For: (please tick)

Receive Pathology / Radiology Results
Receive Referral, Status and Discharge Reports
Send Electronic Letters
NOTE: Please ensure your Clinical Software has the capability to send electronic
letters using HealthLink

Which Hospitals or Laboratories will be sending data to you?

HealthLink VPN Application
(This section should only be completed by Laboratories submitting an application
on behalf of a practices with no Internet connection)

Does this practice require a HealthLink VPN connection?    YES

Comments or Special Delivery Instructions

Service Agreement *

Full Name
Position

I hereby apply on behalf of the afore mentioned practice / organisation to use the services
offered by HealthLink Ltd and agree to comply with all terms and conditions set out in the
HealthLink Service Agreement including all schedules published at healthlink.net.

  Unable to view the Service Agreement? Click here to download the Adobe Reader