Panorama Inventory - First Nation Request Form

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P
I
- F
N
R
F
ANORAMA
NVENTORY
IRST
ATION
EQUEST
ORM
Instructions: Please fill in this form, print it, and sign it (2 pages in total). You may then either: fax the completed and
signed forms to the eHealth Service Desk at 306-781-8480 or scan the completed and signed forms then email them to
ServiceDesk@eHealthsask.ca.
If you require additional assistance please call the eHS Service Desk at: 1-888-316-7446 (local 306-337-0600).
R
O
I
:
EQUESTING
RGANIZATION
NFORMATION
Organization Legal Name
(i.e. Depot Site, Clinic,
etc.):
_______________________________________________________________________________________________________________________________
Street Address: ____________________________________________
City: ___________________________________________________
Postal Code: ________________________________________________
Email: _________________________________________________
Telephone: _________________________________________________
Fax: ___________________________________________________
Designation of Authorized Approvers
Please fill out the following section with a minimum of 1 Authorized Approver. Approvers will receive email
notification to verify that the members of your Organization who request user rights to the Panorama Inventory
(“Users”) are allowed to have access.
P
A
A
ANORAMA INVENTORY
UTHORIZED
PPROVERS
Last Name
First Name
Email Address
F
L
(I
1
)
ACILITIES
IST
F THERE ARE MORE THAN
FACILITY THAT THE ORGANIZATION IS RESPONSIBLE FOR
V. 2014-04-10
1

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