Fuji PACS Registration

Practice Legal Name(Required)

Practice Branded Name(Required)

Practice Street Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone(Required)

Main Fax(Required)

EMR (Enter NA if none)(Required)

How would you like to receive reports from Windsong?(Required)

Fax

HealtheLink

Name(Required)

First Last

Email(Required)

Title/Credential(Required)

Name

First Last

Title/Credential

Name

First Last

Title/Credential

Name

First Last

Title/Credential

Name(Required)

First Last

Email(Required)

Title

*Contact info will not be shared outside of the practice