Individual EMIS Extract Services/EMIS SSO - Request Form
This request form ideally needs to be completed by the appropriate Success Team Member on behalf of the GP/Health Care provider already using PKB.  However, this request form can partially be completed by the GP Practice as long as they specify the Success Team Member managing their deployment who can then complete the non mandatory sections later.
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Which EMIS-PKB services do you require implementing (Please tick)? *
Required
Please provide the PKB Org Name
Please provide the PKB Org Code
Please provide the PKB Team Code
Please provide the full name of the GP Practice contact *
Please provide us a contact number at the GP Practice *
Please provide us an email address for the contact at the GP Practice *
What is the name of the requesting GP Practice? *
What is the postcode of the requesting GP Practice? *
What is the NACS Code of the requesting GP Practice *
What is the EMIS CDB number (if known)
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