VPN Request Form - ZorgDomein

Customer details

Company name:*
Contact:*
Phonenumber:*
E-mailaddress:*

Contactdetails ZorgDomein

Company name:ZorgDomein
Department:IT Support
Phonenumber:020 - 471 5282
E-mailaddress:ITsupport@zorgdomein.nl

Contactdetails Network Administrator

Company name:*
Contact:*
Phonenumber:*
E-mailaddress:*

Current settings VPN connection

Endpoint IP-address old:
Mailserver IP old:
E-maildomain old:
HL7 Server IP (Production environment) old:
HL7 Server port (Production environment) old:
HL7 Server IP (Test environment) old:
HL7 Server port (Test environment) old:

New settings VPN connection

Endpoint IP-address new:
Mailserver IP new:
E-maildomain new:
HL7 Server IP (Production environment) new:
HL7 Server port (Production environment) new:
HL7 Server IP (Test environment) new:
HL7 Server port (Test environment) new: