Information Required Before a Telemedical Link Will Be Set Up If you are a human and are seeing this field, please leave it blank. 1. Name of Hospital/Clinic/Practice 2. Postal Address of Hospital or Clinic (Doctor) 3. International Phone Number(s) 4. Name of Hospital Director 5. Named Administrator Responsible for Telemedicine Referrals 6. Email Address(es) for the Clinician Who Will Be Using Telemedical Link 7. Type of Hospital/Clinic/Practice (i.e. teaching, specialist, local, community, etc...) 8. Specialist Services Available On-Site 9. Do You Have a Means of Taking a Digital Photo and Have an Active Email Link with Web Access? (Select One) Yes No 10. Will the Hospital Undertake to Advise the Consultant Answering Referrals as to the Outcome of Each Case? (Select One) Yes No 11. How Many Doctors, Nurses and Other Trained Medical Staff Are There? 12. What Type of Diagnostic Equipment is Available? 13. How Many Beds?