Customer Information for Centricity Interface Integration by tyndale

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									                     Welch Allyn device/Centricity Interface Questionnaire
If you have Questions Please Call us at: (650) 345-8685
Email this completed Form to: contact_us@polaris-danforth.com
Or Fax this completed Form to: (650) 240-0626

Customer Information for Centricity Interface Integration
Welch Allyn Contact
phone, email
Customer Name
Address

Phone, Fax
Customer business contact (phone, email)

Customer IT contact (phone, email)

Request for Demonstration (Yes/No)
Demo for which device interfaces?
Desired date or contact to arrange
Request for Quote
Device Interfaces (which)
Vital Signs Devices (Type/model) Spot,
Lxi, other…
Quantity each Vital Signs Device (Spot: #,
Lxi: #, …)
Scale (Quantity)
ECG device (Quantity)
Stress ECG device(Quantity)
Spirometer device (Quantity)
ABP device (Quantity)

IT Environment
GE Centricity EMR version (5.6 or 2005)
Centricity over CITRIX (Yes, No)
Centricity over Terminal Server (Yes, No)
Comments/Special Requests:

								
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