Vessel Renewal Form

Location Information

In this section, we collect some important information about your location.

Location/Vessel/Project Name *

Max # of people at the location or onboard the vessel? (Do not include Guests) *

Where is the location, or where is the vessel home port? Please include the address. *

What is the primary type of location/vessel? *

Are Telemedicine services required for this location? *

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? *

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? *

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? *

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? *

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? *

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

In this section, you can upload a copy of the Medications available at your location. This is very important so that PRAXES Doctors to know what they can recommend and prescribe.

Do you have a Medical Kit on-site at the location? *

Please upload an Excel, Word or PDF copy of your Medical Kit at your location. (Optional but preferred)

Click or drag files to this area to upload. You can upload up to 10 files.

Acceptable 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,

Caller Information for Telemed Services

In this section, we ask you whom the Callers will be using the Telemedicine Service that are onboard the vessel. You can add up to 4 callers. It is important for us to gather these details, especially so that we can understand the skill level/training of the people onboard that will be calling us.

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? *

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? *

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? *

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

Vessel Renewal Form

Please complete this form for each vessel that requires renewal or re-activation. This ensures PRAXES has accurate information on-file.

Location Information

Location/Vessel Photo

Company / Organization Information

People Covered

Medical kit

Caller Information for Telemed Services

Special instructions

Terms and Conditions