Registration - Antech Imaging Services

"*" indicates required fields

Primary purpose you are registering with AIS*

Send Consults for Interpretation

RapidRead (AI interpretation)

PennHIP

Data Storage

Practitioners*

First Name

Last Name

Point of Contact Name*

First Last

POC Phone Number*

POC Email Address*

Enter Email Confirm Email

Practice Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Phone Number*

Extension

Practice Email Address*

Enter Email Confirm Email

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Phone

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