Your Company Name
Address Line 1 (e.g. 123 Main Street)
Address Line 2 (e.g. Apt 2a)
City      State    Zip

Phone    Fax

Your Customer's Name
Person to Contact at Site
Voice Phone at Site
Address Line 1 (e.g. 123 Main Street)
Address Line 2 (e.g. Apt 2a)
City      State    Zip

Provider Entry (Pick one from 1-4 below
1) Single Provider
2) 1st Provider is constant.  Providers 2-3 are selected from list.
3) Providers 1-3 are selected from list.
4) 1st Provider is selected from a Primary list.  Providers 2-3 are selected from a secondary list.

Primary doctor numbers (e.g. X345, X346).

Secondary doctor numbers (e.g. X34, X334)

Report Print after Download to MultiLink from your lab computer :
Ask user whether to print
Do not ask and do not print
Print reports without asking

Label printer: Dymo-CoStar XL Plus or Datamax

Modem:

Customer uses Social Security Numbers or to identify patients.
If not SSN, is the format of patient ID numeric or alphanumeric?

This customer will accession or log specimens on MultiLink
This customer will register patients on MultiLink
This customer will only receive results on MultiLink
My lab already registers all patients for this customer on MultiTech

   Optional Features that will be used by this site:
MultiLink Scheduling
Report Generator

Computer Company Name
Address Line 1 (e.g. 123 Main Street)
Address Line 2 (e.g. Apt 2a)
City    State   Zip

Contact Name   Phone

Thanks for filling out all fields on this form.  We need all of the information to get you started with MultiLink.  Please make a copy of this form for your records.

   Authorized By
Name   Title
Purchase Order