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Registration of Imaging center or Hospital facility:

First name: *

Last name: *

Email: *

Password: *

Confirm password: *

Facility Name: *

Facility Website:

Facility Phone:

Facility Fax:

Facility Country: *

Facility State: *

Facility City: *

Facility Zip: *

Facility Address: *

Facility Type:

Contact Email:

Description:

Use appointment calendar

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Modalities:

Insurance:

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Servicing Area(s):

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Referring Physicians:

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