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Contact Submission Form
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First Name
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Last Name
*
1,true,1,Last Name,2
Contact Email
*
1,true,6,Contact Email,2
Secondary Email
1,false,6,Secondary Email Address,2
Phone
*
1,true,1,Phone,2
Job Title
*
1,true,1,Job Title,2
Hospital or Cardiac Rehab
*
1,true,1,Company Name,2
Address
*
1,true,2,Address,2
City
*
1,true,1,City,2
State
*
1,true,1,State,2
Zip
*
1,true,1,Zip Code,2
Current Telemetry Manufacturer
1,false,1,Manufacturer,2
Equipment Age
1,false,10,Equipment Age,2
1- 3 Years
1,false,10,Equipment Age,2
4 – 6 Years
1,false,10,Equipment Age,2
7 – 10 Years
1,false,10,Equipment Age,2
10 Years or More
Measure Clinical Outcomes
1,false,10,Measure Clinical Outcomes,2
Yes
1,false,10,Measure Clinical Outcomes,2
No
Purchasing timeframe
1,false,10,Purchasing timeframe,2
0 – 1 Months
1,false,10,Purchasing timeframe,2
2 – 3 Months
1,false,10,Purchasing timeframe,2
4 – 6 Months
1,false,10,Purchasing timeframe,2
7 – 12 Months
1,false,10,Purchasing timeframe,2
More than 12 Months
1,false,10,Purchasing timeframe,2
No timeframe
Interests
Cardiac or pulmonary rehab patient monitoring
Rural health patient monitoring
Interfacing and clinical IT solutions
Cardiac or pulmonary reporting
Special financing options
Certified on-site training
Free evaluation of my existing system and patient-care process
Request an on-site demo
For Life Support Programs – Loaners, Tech Support, Software Updates
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Notes and Comments
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