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PACS Login Request

Covington Diagnostic Imaging Services, Valley Medical Center, Valley Diagnostic Imaging Services, & and Valley Breast Center

Last Name:                             First Name:            
   

Please check any of the following designations that apply.
MD            ARNP          PA-C

Practice / Affiliation:

Address:

City:                                 State:                              Zip:
         
Phone Number:  (Required)      Extension:
          
E-Mail Address:



Additional Logins For Your Office?
Please fill in the names of any other staff at your location that will need a PACS login.
Name 1  
 
Last Name #1:                         First Name #1:            
   

Please check any of the following designations that apply.
MD           ARNP         PA-C

E-Mail Address #1:
Name 2  
 
Last Name #2:                         First Name #2:            
   

Please check any of the following designations that apply.
MD            ARNP          PA-C

E-Mail Address #2:
Name 3  
 

Last Name #3:                         First Name #3:            
   

Please check any of the following designations that apply.
MD            ARNP         PA-C

E-Mail Address #3:
Name 4  
 
Last Name #4:                         First Name #4:            
   

Please check any of the following designations that apply.
MD           ARNP         PA-C

E-Mail Address #4:
Name 5  
 
Last Name #5:                         First Name #5:            
   

Please check any of the following designations that apply.
MD           ARNP         PA-C

E-Mail Address #5:

Additional Comments: