Please fill out required fields and press 'Submit' button
Name *
Street *
Suburb *
Postcode *
Email address *
Manager/Contact Name *
Phone number *
Fax number
Full name *
Type *
Provider number *
Specialty *
Starting date (If known)
Finishing date (If known for Registrars, Locums and Interns)
Name
Provider number
Street
Suburb
Postcode
If the referrer requires access to I-MED Online, click here
Full name
Email address
Phone number
What Operating System does the computer you intend to install our software on use? *
Please indicate which Practice Management Software your Practice has *
Do you have a Local Area Network (LAN) in the practice?
Are you installing for a single user/laptop use?
URL for download: http://www.promedicus.com.au/support/support-files
For all new installations you will be contacted by ProMedicus support who acts on I-MED's behalf. When the form is completed, a ticket number will be sent to you automatically and our referrer support team will be in contact. If you haven’t been contacted after 48 hours of submitting the form, contact I-MED Referrer Support on 1300 147 852 or email referrer.success@i-med.com.au.
TERMS OF ACCEPTANCE OF NOMINATIONI/We, the Practice named above, accept your nomination that I/we be appointed as a registered user of the Promedicus.net Secure Email System. I/we understand that this will require my/our agreement to install the Promedicus.net Client Software on my/our computer. I/we understand that I/we may either accept or reject the installation and acceptance will be on the terms of the “Licence Agreement for Use of the Promedicus.net Secure Email System by Nominated Recipient”. I/we agree that any person who installs the Promedicus.net Client Software on my/our computer does so as my/our agent on my/our behalf. These terms may be viewed by accessing http://www.promed.com.au/terms-of-use/ or by reading the licence agreement displayed when installing the "software"
Full Name and Role *
Date *
