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ECM flow application
Please fill out and submit the following form. You can save and continue the form at a later stage if you don't have all the information at hand.
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1
Details of person representing the practice
Name and surname of representative
Role
Name of practice
Please enter your email
Please enter your cellphone number
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2
Name of hospital / address of practice
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3
Details of administrator of your system
This can be changed on the system. This can be the same as the representative. This person will have offsite access and be able to add staff and assign roles. You can change / assign more than one administrator at a later stage.
Name
Email address
MP number
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4
Requested date to start running ECM Flow
-
Date
Day
Month
Year
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5
Select locations/ bed names needed
Please add extra as needed
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6
If you would like assistance to upload the list of emergency centre doctors working in the unit, please attach a list of your doctors below (include MP number and email address).
(You can add doctors individually yourself on the system at a later stage)
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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7
If you would like assistance to upload the list of nurses working in the unit, please attach a list of your nurses below (include email address).
(You can add nurses individually yourself on the system at a later stage)
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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8
If you would like assistance to upload list of specialists working with the unit, please attach a list of your specialists (include the speciality and their cellphone numbers).
(You can add specialists individually yourself on the system at a later stage)
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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9
What internet do you have access to in your unit?
Very little data needed.
Own private internet
Hospital registered account
Free hospital wifi
Other
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10
What is the IP address of the internet service in your unit? This allows the system to be locked down so it can only be accessed at your unit. Only users that are assigned as administrators will have access offsite.
Open the browser on any computer in your unit and type - "What is my IP". (example- 170.0.12.345)
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11
What computers do you plan to use for the system?
If using hospital it will depend on permissions and timeout/hibernation settings of different hospital groups.
Private/ personal computers
Hospital
ECM flow hardware
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12
How many stations are you planning to have in your unit? (ECM hardware consists of Raspberry pi's pre-setup for the ECM Flow system. Monitor, keyboard and mouse not included)
Suggested stations - Triage computer, Main Nurses/ duty station, Display board. Optional extra of waiting room.
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13
Payment details - Monthly invoice
Payments will commence after the 30 day free trial. Reminder emails will be sent.
Name to be used on invoice / name of practice or company
Email address for invoice
VAT number
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14
Which date would you like to receive the first reminder of the free trial ending?
(You will be selecting a second date on the next slide)
-
Date
Day
Month
Year
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15
Which date would you like to receive the second reminder of the free trial ending?
-
Date
Day
Month
Year
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