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PathWest Direct
PATHWEST DIRECT SET UP
FOR COMMERCIAL SITES
STEP 2.
You have 2 options in how you choose to get your information to us:
OPTION 1:
You can choose to either download the Commercial Site Questionnaire (PDF Format), print it out, complete it and fax it back to us on
(08) 9346 7369.
PDF Format (100 Kb)
Click here if you do not have the Abode Reader, to download it.
OPTION 2
:
For a more rapid system deployment,
simply complete the on-line form below and submit it directly to our Marketing Department.
COMPLETE THE ON-LINE FORM BELOW AND CLICK ON 'SUBMIT '
COMMERCIAL CLIENT DETAILS
Business Name:
Head Office Address:
ACN \ ABN:
Head Office Contact:
Head Office Phone:
Head Office Fax:
Head Office Contact Email:
SITE DETAILS
Ignore this section if your Business has only one primary site as described above
Site Name \ Location:
Site Address:
Contact name:
Phone Number:
Email Address:
Fax Number:
IT SUPPORT STAFF DEATILS
IT Support person:
Phone Number:
IT Support email:
Mobile Number:
REFERRING CLIENT DETAILS
PERSON TO RECEIVE RESULTS
POSITION HELD
Eg. John Smith
Eg. OH& S Officer. Foreman, Owner
COMPUTING ENVIRONMENT DETAILS
Please select your computer's operating system:
--Select Operating System--
Windows 98
Windows NT
Windows 2000
Windows XP
Other - Please specify below
Please type your operating system if not listed above:
Please select your type of internet connection:
--Select Internet connection--
Dial-Up Modem
ADSL Broadband
Cable Broadband
Satellite Broadband
Long Range Wireless
Radio Link (line of sight)
RETROSPECTIVE ELECTRONIC REPORTS
Would you like retrospective reports for the above referrer ?
No
Yes
NB: If No is selected, reports will commence being processed from the date of system setup
If Yes, please specify starting date:
Form Completed by:
© PathWest Laboratory Medicine WA 2005 |
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