MED IP Services Request Form

NOTE: If this is a device that is NOT supported by PMACS, the use of the device on PennNetworks needs to be vetted by PennMedicine Information Services Security Assurance. Please email details to David Wargo at david.wargo@pennmedicine.upenn.edu

Please fill out as much information as possible. If this is a delete or change request, you will only need to fill out the following fields:
- Your Email Address
- Department
- Comments

Request Type:
Your Email Address:
Department the IP Address is for:
26 Digit Budget Code:
Building:
Room Number:
Primary User:
Suggested DNS Name:
Type of Device:
Device Vendor:
Comments
Please enter any comments related to this request. If you are deleting, please enter both IP addresses and DNS names. If you are making changes, please include all information including IP and DNS information below. For bulk requests please upload a bulk request form.
Bulk Request file upload. Download template here.

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