User Registration Form Sample Clauses

User Registration Form. The following form has to be completed in order to be registered as a user of the APC Flow Cytometry Platform. The form can be easily completed with the help of your departmental administration. The form must be presented to the manager of APC Flow Cytometry Platform prior to any use of the facility.

User Registration Form. It is agreed that the user identified on this form, has read and accepted the conditions outlined in the e-Results Terms of Use Agreement (which can be reviewed at xxx.Xxxxx-Xxxxxxxx.xxx). By signing this Registration Form you agree to be individually bound by the Terms of Use that a member of your organization has already signed on behalf of your organization. If you intend to use a third party software tool to process e-Results, the vendor or support staff of the third party software must agree to be bound by the same conditions contained in the Terms of Use Agreement. The user identified on this form will be provided with a unique user id and password which will be used to access resulting information assigned to your organization. Multiple users may have access to the same information, with the processing of such information to be managed by the various users. Organization / Cilnic / Company Physician Name Last name First name OHIP Billing #: User Name (if different than physician) Last name (if applicable) First name Address: City: Postal Code: Email Address: Extension: - ( Phone number: ❑ Downloaded into your EMR (if selected, please fill in the remaining items on the form) EMR Provider Name: Software version: EMR Contact name: ❑ Viewed and/or printed from GDML website only Results to be: (choose only one) - ( ) - Province: Phone number: