Healthcare Providers - Registration

Register for access to the NWO Pandemic Flu Healthcare Providers portal.

DISCLAIMER: Due to the potentially sensitive nature of the material on this website and the need to limit distribution of the material, please provide the following information:

First Name:
Last Name:
Organization / Employer:
Job Title:
Address:
C/S/Z:
Business Phone #:
Business Fax #:
Email:
How will you use the information provided on nwopandemicflu.org in your current position?:
A contact person within your organization/employer is needed in order to verify your affiliation with your organization/employer
Contact Name:
Contact Phone #:
Contact Email:
If you are self employed and cannot provide a contact person to verify your affiliation with an organization/employer, please provide your license number
License #:
Please enter your requested user name and password
User Name:
Password:
Verify Password:
Attention Physicians and Physician's Office Staff For physicians and physicians' offices, Northwest Ohio has available an emergency event notification system called HipLink. This system enables cell phone users with text capability, offices with fax capability, and those with email addresses to receive alert notifications in the event of a significant health-related emergency and/or incident occurring in Northwest Ohio. To register for HipLink please provide the contact information below for any communication options you wish to register to receive alert notifications.
First Name:
Last Name:
Cell Phone:
Cell Phone Service Provider (e.g. AT&T, Verizon):
Office Fax:
Office Fax 2:
Office Fax 3:
Office Fax 4:
Email:
Email 2:
Email 3:
Email 4:
If you register your office fax number, please advise your office manager about the HipLink system. Once your contact information is registered in the HipLink system, you will receive a test message from the Hospital Council of Northwest Ohio welcoming you to the system.