Validation Code Request Form

Quick guide to the request process
* MIMS on PDA software must be installed on your device before continuing

Unique ID: enter the special ID as supplied by your hospital for this form
Name: enter your name here
Hospital: select the hospital you are working with
Department: enter the department you are working in
Software Version: select the version of MIMS on PDA you have installed
User Name: enter your username as shown on MIMS on PDA validation screen
Activation Code: enter your activation code as shown on MIMS on PDA validation screen
E-Mail Address: enter your hospital email address here; only use a private email address if a unique ID is used
Unique ID:
check here if you need one
* Name:
* Institution Name:
Department:
* Product

*

PDA Username:
*

Activation Code:
* E-Mail Address:

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