Site Intake - eChart Manitoba

Please indicate the service(s) that you are interested in*

eChart Manitoba

eHealth_hub – DI

eHealth_hub – Labs

eHealth_hub – CR Query Service

eHealth_hub – Enrolment Service

eHealth_hub – Home Clinic Client Summary

eHealth_hub – Immunization Query Service

PART 1: SITE INFORMATION

Please enter the following information about your site.

Site Legal Name*

Site Common Name

(if different than legal)

Address*

Street Address City Postal Code

Site Telephone Number*

Site FAX Number

Site Email Address*

PART 2: PRIMARY CONTACT INFORMATION

Person responsible for working with Digital Health, Shared Health during implementation.

Name*

First Last

Job Title / Position

Telephone Number*

Site Contact Email*

How would you describe your site?*

Health centre

Hospital / acute care

Long term care and rehab

Nursing station

Primary care

Specialty clinic

Other

Other Site Type

(please specify)

Does your site use an EMR?*

Yes

No

Name of EMR?

(please specify)

PART 3: ADMINISTRATIVE

Who owns and operates your site?*

Federal

Fee For Service

First Nations

Provincial

Regional Health Authority

Shared Health Program

Other

Which Regional Health Authority?

(please choose)

Other Owner or Operator's Name?

(please describe)

PART 4: APPLICATION APPROVAL

All applications must be approved by the appropriate authority for the site prior to submission (e.g. CEO, Program Director, clinic owner). Please indicate the name and title of that person below.

Approving Authority Name

Approving Authority Title

Email

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