This form may contain personal information pursuant to the ‘Personal Information Protection and Electronic Documents Act’ (PIPEDA). This form and its contents should not be distributed, copied or disclosed to any unauthorized persons. If you have accessed this form in error please contact OTN at 1.866.454.OTN1 (6861) immediately. Version 1.1 Personal Videoconferencing (PCVC) Account Request Organization Information Organization’s Legal Name: Site Name (if existing member): Site No. (if existing member): LHIN: Address: Suite No.: City: Province: Postal Code: Signing Authority Salutation: ☐☐ Dr. ☐ Mr. ☐ Ms. ☐ Miss. First Name: Last Name: Title: Phone: Fax: Email: Primary Contact Salutation: ☐☐ Dr. ☐ Mr. ☐ Ms. ☐ Miss. First Name: Last Name: Title: Phone: Fax: Email: Users 1 First Name: 2 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 3 First Name: 4 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 51 First Name: 6 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 7 First Name: 8 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 9 First Name: 10 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 11 First Name: 12 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 13 First Name: 14 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: 15 First Name: 16 First Name: Last Name: Last Name: Email: Phone: Email: Phone: Profession: Provider Service: Profession: Provider Service: Technical Support First Name: Last Name: Title: Phone: Fax: Email: “Provider Service” definition: The main area of expertise for which a consultant offers telemedicine services. E.g., cardiology or psychology. HST Exempt? ☐ Yes ☐ No HST Exemption No.: The above is a request to purchase OTN Personal Videoconferencing account(s). Each User will be required to complete an individual application and accept the Terms and Conditions via the Telemedicine Centre. Service accounts are associated with individual email accounts. Shared accounts are not permitted under the service agreement. Office Use Only – Special Notes OTN Account Manager: Date: Please send the completed from to [email protected]
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This form may contain personal information pursuant to the ‘Personal Information Protection and Electronic Documents Act’ (PIPEDA). This form and its contents should not be distributed, copied or disclosed to any unauthorized persons. If you have accessed this form in error please contact OTN at 1.866.454.OTN1 (6861) immediately. Version 1.1
Personal Videoconferencing (PCVC) Account Request Organization Information
Organization’s Legal Name:
Site Name (if existing member): Site No. (if existing member):
LHIN: Address: Suite No.:
City: Province: Postal Code:
Signing Authority
Salutation: ☐☐ Dr. ☐ Mr. ☐ Ms. ☐ Miss.
First Name: Last Name: Title:
Phone: Fax: Email:
Primary Contact
Salutation: ☐☐ Dr. ☐ Mr. ☐ Ms. ☐ Miss.
First Name: Last Name: Title:
Phone: Fax: Email:
Users
1 First Name: 2 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
3 First Name: 4 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
51 First Name: 6 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
7 First Name: 8 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
9 First Name: 10 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
11 First Name: 12 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
13 First Name: 14 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
15 First Name: 16 First Name:
Last Name: Last Name:
Email: Phone: Email: Phone:
Profession: Provider Service: Profession: Provider Service:
Technical Support
First Name: Last Name: Title:
Phone: Fax: Email:
“Provider Service” definition: The main area of expertise for which a consultant offers telemedicine services. E.g., cardiology or psychology.
HST Exempt? ☐ Yes ☐ No HST Exemption No.: The above is a request to purchase OTN Personal Videoconferencing account(s). Each User will be required to complete an individual application and accept the Terms and Conditions via the Telemedicine Centre. Service accounts are associated with individual email accounts. Shared accounts are not permitted under the service agreement.
Office Use Only – Special Notes
OTN Account Manager: Date: Please send the completed from to [email protected]
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