Electronic Medical Record
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your role in palliative care?
*
Which tool(s) are you requesting to use?
*
Palliative Performance Scale Version 2 (PPSv2)
Bereavement Risk Assessment Tool
Bowel Performance Scale
Respiratory Congestion Scale
Psychosocial Assessment Tool
10 Steps for Better Prognostication
Which languages are you requesting the tool(s) to be in? Please specify below what languages
English
Arabic
Thai
Type option 4
Would you be using the tool(s) for profit?
*
Yes (add details below)
No
Please provide more information abut how you will use the tool(s)
*
Do you agree that the tool will only be used within an EMR system in clinical settings? Distribution of the tool(s) outside this context is not allowed.
*
Yes
No
Please read the instructions to add PPSv2 to Electronic Medical Record (EMR)
Please see the sample version of PPSv2 below. Attach a screenshot of your EMR system clearly showing the complete PPSv2 table with definitions and instructions:
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Please review and check each clause to confirm your agreement with the copyright terms:
*
Permission is granted for non-exclusive rights in the specified language(s) only.
A credit line will appear at the bottom of the tool(s) and will include: Copyright Victoria Hospice Society, BC, Canada www.victoriahospice.org.
No modifications to the content, structure and meaning of the tool(s) is allowed.
The tool(s) must be used with complete usage instructions, including the chart, instructions for use and definition of terms.
The tool must not be used in any way that generates profit from the tool itself, outside of the use specified in the application. This includes resale, licensing, or commercial distribution.
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