First name*
 
 
 
 
 
 
Last name*
 
 
 
 
 
 
Email*
 
 
 
 
 
 
Mobile number
 
 
 
Your mobile number is important and will only be used to send you automated important Novari eVisit SMS (text) messages. It will NOT be shared with patients or others and you can control your notifications settings inside the application.
 
 
 
 
Designation
 
 
 
 
 
 
Professional registration number (eg., CPSO ID or CNO ID)*
 
 
 
 
 
 
Practice business name
 
 
 
 
 
 
Clinic or practice phone number*
 
 
 
 
 
 
Clinic or practice fax number
 
 
 
 
 
 
Clinic or practice street address*
 
 
 
 
 
 
Clinic or practice suite (optional)
 
 
 
 
 
 
Clinic or practice city*
 
 
 
 
 
 
Clinic or practice province
 
 
 
 
 
 
Clinic or practice postal code*
 
 
 
 
 
 
Billing number*
 
 
 
 
 
 
Which LHIN is your practice located in?*
 
 
 
 
 
 
Type of Practice*