Electronic Access Application Form

Please use the form below to request for electronic access to Apex Radiology images and reports.

Once we receive your application form, our IT Department will create your account and contact you with your log in details and instructions.

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Practice name*

Select from one of the following*

Profession*

Specialist*

Allied Health*

Address*

Hospital (if applicable)

Healthlink ID (if appropriate)

Email*

Please do not use a generic email address i.e. 'info@...' or 'admin@...' We need your unique email to ensure we can set up your account properly.

Phone Number*

Fax

First Name Last Name

Provider Number*

AHPRA Number*

Do you have a WA Health Number (WA HE Number HExxxxxx)?

YES

WA HE Number*

Additional Information

Date Completed*

Terms & Conditions*

By checking this box you are agreeing to terms and conditions of use Read the terms and conditions here.