CONTACT INFO

Name*:

Title*:

Hospital Name*:

Email*:

Phone*:

Ext:

Mailing Address:

City/State/ZIP:

GENERAL INFO

Department Head Name:

Current Telemetry Provider:

Age of Equipment:
—Please choose an option—1 to 3 years4 to 6 years7 to 10 years10+ years

Do you measure clinical outcomes?
—Please choose an option—YesNo

Do you have a purchasing timeframe?
—Please choose an option—0 to 1 months2 to 3 months4 to 6 months7 to 12 monthsMore than 12 monthsNo, I have no set timeframe

I’m interested in…
Cardiac or pulmonary rehab patient monitoringRural health patient monitoringInterfacing and clinical IT solutionsCardiac or pulmonary reportingSpecial financing optionsCertified on-site trainingI’d like a free evaluation of my existing system and patient-care processRequest an on-site demonstrationFor Life Support Programs (Loaners, Tech Support, Software Updates)

General comments: