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Vessel Renewal Form
Please complete this form
for each vessel
that requires renewal or re-activation. This ensures PRAXES has accurate information on-file.
*Fields with an asterisk are required.
Please enable JavaScript in your browser to complete this form.
Location Information
In this section, we collect some important information about your location.
Location/Vessel/Project Name
*
Max # of people onboard the vessel or at the location?
*
Where is the location, or where is the vessel home port? Please include the address.
*
What is the primary type of location/vessel?
*
Fishing vessel
Scientific/research
Pleasure Craft (Sailing or motor)
Passenger Ferry or Cruise Ship
Industrial Vessel (Seismic, Oil & Gas, Shipping, etc)
Land-based Industrial (Mine, Construction, etc)
Land-based event (Sports, Film, Conference, etc)
Other
Are Telemedicine services required for this location?
*
Yes
No
Will the location need coverage to speak to a PRAXES doctor?
Telemedicine Coverage Start
*
Telemedicine Coverage End
*
Primary Phone number the location can be reached at (Normally the main Satellite Phone)
*
Backup Phone number the location can be reached at (Can be another Satellite phone)
How will the location be calling PRAXES? (i.e. Satellite phone, Mobile phone, VOIP phone, WiFi calling, Landline, etc.)
This helps our technical support team understand what technology is being used, to help support any phone connection issues.
Location/Vessel Photo
This helps provides some context for the PRAXES Doctors when providing medical advice.
Do you have a photo of the location/vessel that you can provide?
*
Yes
No
Upload a Photo of your location/vessel
Click or drag a file to this area to upload.
Acceptable file formats are: .jpg, .jpeg, .gif, .bmp, .png
Company / Organization Information
In this section, we collect some important information about your company/organization and your main company representative. This is the person in your company that PRAXES will reach out to for any business renewals, ongoing operational concerns, and send incident reports to when your vessel calls in for Telemedicine assistance.
Company / Organization Name
*
Name of company representative / main business contact
*
First
Last
Job Title of company representative
*
Email of Company Representative
*
Phone of Company Representative
*
Would the Company Representative like to receive incident reports?
*
Yes
No
Incident reports are sent out anytime this vessel engaged PRAXES Telemedicine service. An alert can be sent to the Company Representative.
Would you like to add a Backup Company Representative?
*
Yes
No
You can optionally add a backup company representative
Name of Backup company representative
First
Last
Job Title of Backup company representative
Email of Backup company Representative
Phone of Backup company representative
Would the Backup company representative like to receive incident reports?
*
Yes
No
Incident reports are sent out anytime this vessel engaged PRAXES Telemedicine service. An alert can be sent to the Backup company representative as well.
People Covered
In this section, you can upload a full list of all of the people that will be covered by PRAXES Telemedicine. Ideally this is a spreadsheet and has First Name, Last Name, Sex, Role on Vessel and Date of Birth.
Do you have a list of the people that will be covered?
*
Yes
No
Upload an Excel spreadsheet of the people being covered
Click or drag files to this area to upload.
You can upload up to 10 files.
Accepted file formats are: .xlsx, .pdf, .xls, .xlsm, .xlsb, .xltx, .xltm, .xlt, .xml, .xlw, .xlr, .xla, .xlam, .csv, .txt, .xps, .doc, .docx, .eps, .ppt, .pptx, .wpd,
Medical kit
Please upload a copy of the Medications available at your location. This is very important so PRAXES Doctors know what they can recommend and prescribe.
Do you have a Medical Kit on-site at the location?
*
Yes
No
Medication Template
Please use the template above to fill in a copy of the Medical Kit at your location, then upload it below:
Click or drag files to this area to upload.
You can upload up to 10 files.
If you're unable to use the template above, please upload your list here and we will try to import it.
Caller Information for Telemed Services
Who onboard the vessel will be calling the Telemedicine Service? This is important so that we can understand their skill level/training. You can add up to 4 callers.
Name of Caller #1. This is the main/primary caller at your location.
*
First
Last
Email of Caller #1
*
Role/Job of Caller #1 (Captain, Medic, Project Manager, 1st Mate, etc.)
*
Medical Role of Caller #1 (First Aider, Registered Nurse, Primary Care Paramedic, etc.)
*
Is there a 2nd caller that you'd like to add?
*
Yes
No
Name of Caller #2
*
First
Last
Email of Caller #2
*
Role/Job of Caller #2 (Captain, Medic, Project Manager, 1st Mate, etc.)
*
Medical Role of Caller #2 (First Aider, Registered Nurse, Primary Care Paramedic, etc.)
*
Is there a 3rd caller you'd like to add?
*
Yes
No
Name of Caller #3
*
First
Last
Email of Caller #3
*
Role/Job of Caller #3 (Captain, Medic, Project Manager, 1st Mate, etc.)
*
Medical Role of Caller #3 (First Aider, Registered Nurse, Primary Care Paramedic, etc.)
*
Is there a 4th caller you'd like to add?
*
Yes
No
Name of Caller #4
*
First
Last
Email of Caller #4
*
Role/Job of Caller #4 (Captain, Medic, Project Manager, 1st Mate, etc.)
*
Medical Role of Caller #4 (First Aider, Registered Nurse, Primary Care Paramedic, etc.)
*
Special instructions
Are there any special notes that you'd like to tell us? (Optional)
Terms and Conditions
Terms of Use
*
Check this box to confirm you have read and agree with PRAXES Terms of Use.
View a copy of our Terms on our website here:
https://praxes.ca/terms
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