Cloud Registration Form

Practice Name *

Type of Practice *

Practice Address 1 *

Practice Address 2

Town/City *

County *

Postcode *

Practice Phone Number *

Practice Manager Name (or Main Contact) *

First

Last

Practice Email *

Email

Confirm Email

Practitioner Account 1: Full Name *

First

Last

Practitioner Account 1: Email *

Email

Confirm Email

Practitioner Account 2: Full Name

First

Last

Practitioner Account 2: Email

Email

Confirm Email

Practitioner Account 3: Full Name

First

Last

Practitioner Account 3: Email

Email

Confirm Email

Practitioner Account 4: Full Name

First

Last

Practitioner Account 4: Email

Email

Confirm Email

Practitioner Account 5: Full Name

First

Last

Practitioner Account 5: Email

Email

Confirm Email

Type of Radiographic System