Private Clinic Change "*" indicates required fields Site Name Site Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Site Contact Name* Phone numberSite 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 CommentsTo avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).