Please enter your details below
Name *
Email *
Address *
City *
State *
Postcode *
What is your clinic name? *
What is the clinic's number? *
Do you have administration access to the Practice Management System? *
Please indicate which Practice Management Software your Practice has *
What I-MED clinic do you normally refer to? *
IMPORTANT NOTICE:The person who conducts the installation needs administrator access to the server. If your IT service provider will be conducting the installation - please log a request with your IT and provide us with their contact details and the ticket number where required.
IT provider
IT contact name
Contact number
Ticket number
An I-MED team member will be in contact to confirm a suitable date and time to complete the installation.
How did you hear about I-MED e-Referrals *
