New or Updated Practitioner

Person completing this form(Required)

Your Email(Required)

Reason for completing this form(Required)

New Practitioner / Provider Number / Clinic

Modification of Practitioner Details (Name, Provider Number etc)

Other (explain in General Comments)

Practitioner Details(Required)

Title First Last Provider Number (Required) Specialty

Clinic Details(Required)

Fax Number &/or Email(Required)

You can include both here if they have them

Online Access

Electronic (ERT) - Practice Management Software - Please provide Fetch ID if known

CIG Online (Zed/PACS/Results Portal) - Practitioners direct Email is necessary for this

Referrer can register for an online account by completing the form at www.canberraimaging.com.au/cigonline/

ERT Fetch ID (for electronic results)

Practice Management System

Best Practice

Genie/Gentu

Medical Director

Other

Other Practice Management System

Sonic Dx Username: (for electronic reports only - no images via this method)

General Comments

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