Provider Support and Training

Diagnostic X-Ray Imaging Course Registration Form

Name(Required)

First Last

Phone

Email(Required)

Applicant Employer

Applicant Profession

Work Address

Do you work for a Tribal Health Organization?(Required)

Yes

If no, provide name of approving adminsitrator

Approving Administrator Phone

Image processing used at your facility (check appropriate)

Computer Radiography (CR) - Fuji

Computer Radiography (CR) - Konica

Computer Radiography (CR) - iCR

Wet chemistry / film processor

Use both CR and wet chemistry