Private Clinic Change

To ensure your submission is accepted, please avoid using any special characters in the form below, such as: ! ‘ # $ % ^ & * ( ) ?, etc.

"*" indicates required fields

Site Name

Site Address*

Street Address City Province Postal Code

Site Contact Name*

Phone number

Site Contact Email*

Please check each Shared Health service you currently have.

eChart Manitoba

eHealth_hub

Home Clinic Portal

other

Other Service

Please select any changes that apply.

Has the clinic physically moved?

Has the clinic changed legal name or ownership?

Are you making any changes to your EMR vendor?

Are you moving to an ASP hosted vendor?

Are you making changes to your local network?

Is your Internet service provider changing?

New Site Address

Street Address City Province Postal Code

Legal name or ownership change

Who is your current EMR vendor?

Which EMR vendor are you moving to?

When is your go-live date?

DD dash MM dash YYYY

Who is your current EMR vendor?

Which ASP hosted EMR vendor are you moving to?

Local network changes

Upgrade server

Decommissioning server

Upgrade server details

Decommissioning server details

Date of Change

MM slash DD slash YYYY

Comments

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