Telehealth @ UHN

Non-Clinical Video Conference Request Form

* indicates mandatory field        = view calendar
 
PRIMARY CONTACT DETAILS
* First Name:
* Last Name:
* Department:
* Telephone Number:
* Email Address:
 
SECONDARY CONTACT DETAILS
(Complete if event is organized by another hospital)
First Name:
Last Name:
Organization:
Telephone Number:
Email Address:
 
BILLING DETAILS (See fees below)
* Not required for Patient Education and clinical case conferencing. Enter "N/A" in each field.
* First Name:
* Last Name:
* Address:
* City:
* Postal Code:
* Telephone Number:
* Email Address:
 
FEES

Per Event Charge with One UHN Site
$75.00 (Technical Service Fee) + ($75.00 per hour of Video Conferencing)
Example:
1 UHN site + 1 hour of video conferencing = $150.00
1 UHN site + 2 hours of video conferencing = $225.00

For Each Additional UHN Site, add $75.00/event
Example:
2 UHN sites + 2 hours of video conferencing = $300.00

* 48 hour cancellation notice required or charges may apply.
* Organizer will be notified in advance and responsible for long distance charges.
* Rates subject to change upon notification.

* I agree to the above charges N/A

 
EVENT DETAILS
* Event Type:
 Education
Administrative Meeting
Other
* Event Name:
* Event Chair
* Event Date:
(or start date if multiple dates)
* Start Time:
* Stop Time:
If this event occurs more than once throughout the year please provide additional dates
Presenting Hospitals/Locations:
(eg. TWH/Sunnybrook)
 
ROOM DETAILS
(You must make your own room reservations)
* Room Booked:
(Room needs to be booked 30 min prior to start time)
Yes No
* Room Number:
*If Room Number is unknown, put "Unknown" into this field.
Number of Participants at UHN:
(approximately)
 
CONNECTING SITE DETAILS
* Location of Remote Sites:
(Remote site information not required. UHN Telehealth will provide you with self-registration information to send to your participating sites)
 Ontario Out of Province
 
Webcasting:
 Yes No
Download the Following Attachments:
• Request Form
• Agreement Form
   
Additional Information:



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