Set up your new doctors

Practice Details

Practice Name

Practice Manager / Contact Name

Practice Address

Practice Email

Practice Contact Number

Practice Fax

After Hours Number

Practitioner Details

Practitioners

Practitioner details 1

Title

First Name

Last Name

Mobile

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Provider Number and Address

If multiple locations, please enter each provider number and address on a new line

Qualification

Film Preferences

Film free

Benson Connect
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Download to clinical software

Hard copy films

Additional Information

More information

Please include any other information you feel is relevant, eg has this doctor ceased consulting at any other locations.

Referrer information

Set up your new doctors

Practice Details

Practitioner Details

Additional Information