EYEGP Image Reporting System (EIRS)

Centre Information

1 *

Centre Name

2 *

BRN - Business Registration Number

3 *

TIN - Tax Identification Number

4 *

Fundus Camera Availability

Yes

No

5 *

Is your organization a single-location business or part of a larger chain or group?

Single location

Part of a chain or group

* If Part of a chain or group, is your organisation the headquarters (HQ)?

Yes

No

a *

If this is not the HQ, please specify the location of your headquarters (HQ)

b *

Does your headquarters require access to reports or data from all locations in the chain?

Yes, the HQ requires access to consolidated reports

No, the HQ does not require access to reports

6 *

Centre Address

* Address L1
Address L2
Address L3
City		* State
* Postcode		* Country

7 *

Centre Contact Info

* Work Phone (1)		Extension Number (1)
Work Phone (2)		Extension Number (2)
* Email		Fax Number

8

Website

9

Upload company Logo
(This logo will be used for display in EYEGP website)

Clear

10

Notes / Remarks (if any)

Billing Information

1 *

Billing Information
(for Invoice)

* Bill to (company full name)
Billing address same as Centre address
* Address L1
Address L2
Address L3
City		* State
* Postcode		* Country

2

Bank Name
Name of the bank (e.g. "HSBC")

3

Bank Branch
Specific branch or location

4

Bank Address
Full address of the branch (optional)

5

Bank Account Name
Name on the account

6

Bank Account Number

7

Remarks

User Information

#	Access rights by user group:
1	Doctor / Owner (Administrator)	Own centre data: Data entry module, Report module, Invoice module
2	Coordinator (Administrator)	Own centre data: Data entry module, Report module, Invoice module
3	General User	Own centre data: Data entry module, Report module

Notes:
i) Fill in the User Authorisation List below to grant access to your centre's records. Refer to the table above for definitions under the "User Group" column.
ii) Must have at least one user accout. Click the green 'Add' button to add user.

User Authorisation List
No.	Title e.g., Mr, Ms, Dr	Full Name *	Role / Designation	User Group *	Mobile phone Number	Email Address * This will be used for password recovery. Duplicate email addresses are not allowed.

* I certify that the individuals listed above are appropriately trained, understand the importance of maintaining data confidentiality and integrity, and are authorized to perform the tasks described above.

* Verification Code
(Enter the characters you see)

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