Third-party add-on / integration request

Use this form to request the installation or removal of a third party add-on or integration.

Requestor Email: *

Practice Name: *

Third Party Name: *

Request Type *

Enter the add-on or integration's name: *

Is this a Medtech certified add-on or integration? *

Medtech authoriser: *

Enter name of Medtech Manager who has authorised the installation of an uncertified add-on

Purchase Order:

Enter Purchase Order number if required

Date / Time preferred for installation / removal: *

Urgency Level of Request:

Medtech Engineer to install? *

Yes

If 'YES' we will make contact to provide access to the server.

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