DSP Connectivity Request - Agence eSanté Luxembourg

Following your discussion with the project manager of Agence eSanté, please kindly complete the following form. A non-disclosure agreement (NDA) will be sent to you before sharing any information or other specifications with Agence eSanté.

* Company name:

* Company registered office:

* Company registration number:

* Extract from the Companies Register dated within the last 30 days:

* Surname/first name of the legal representative:

* Email address of the legal representative:

Email address of a colleague to be copied in:

* Software product name:

* Software version number:

Software description:

Software type:

General Practitioner software

Hospital Information System

Patient management software

Administrative software

Radiology Information System

Laboratory Information System

Enterprise Application Integration

Other (please specify)