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Request to Open Account for X-Ray Reporting
Please fill all field as informative as possible.
You'll be notified via email upon successful approval.
Name of Clinic
Maximum 50 characters long
Name of Doctor
Maximum 50 characters long
Name of Person
in charged
Maximum 50 characters long
CLINIC ADDRESS:
Street



City
Postcode
State
Country
Phone No 1
Phone No 2
(eg mobile)
Fax
e-Mail
Web
Special Instructions
 
 
Note: We regret to inform that we are no longer accepting new registration via online.
You could print this form and fax or email to us, thank you. 

 

 


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