Please fill out required fields and press 'Submit' button
Practice Name *
Street *
Suburb *
Postcode *
Practice Email *
Manager/Contact Name *
Phone number *
Ticket number (if known)
Full name *
Type *
Provider number *
Specialty *
Name
Provider number
Street
Suburb
Postcode
If the referrer requires access to I-MED Online, click here
Full name
Email address
Phone number
Which connection do you require?
Healthlink ID
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 *
