Remote Deployment Request
Please complete the form below to request a remote installation. A support representative will contact you.
Thank you for completing the form. A representative will be in touch shortly.
Account Number/Facility Name
*
Order Number/PO Number
Primary Contact Name
*
Primary Contact Phone Number
*
Primary Contact Email
*
Preferred Contact Method
Phone
Phone
Email
Email
Product
*
PointClickcare / Matrixcare
Welch Allyn Cardiology Diagnostic Suite
ConnexCS
ELI Link
Pyramis
HeartCentrix
H-Scribe
Q-Stress
Q-Tel RMS
R-Scribe
Web Upload
X-Scribe
CCMD
Vision Express
Vision Premier
Surveyor Central
Cardiograph
E-Scribe
ECG Warehouse
Select the product for which you need assistance
Remote Deployment Type
*
New Installation
Upgrade
Upgrade (Patch)
Re-deployment / re-install
Other
Specify the type of service you require
Remote Deployment Type - Describe
(
?
)
Serial Number(s)
*
Is there / Will there be EMR Connectivity?
*
Yes
Yes
No
No
Do you already have your software for installation?
Yes
Yes
No
No
Number of PCs to assist with
Can you provide or allow a remote connection?
Yes
Yes
No
No
Will you require both a Test and Production environment?
Test Only
Test Only
Production Only
Production Only
Test and Production
Test and Production
Will you require post go-live testing assistance?
Yes
Yes
No
No
What type of IT support is available to you?
Internal IT Dept
Internal IT Dept
External IT Service
External IT Service
No IT Support
No IT Support
IT Resource Name
IT Resource Phone
IT Resource Email
Please indicate the operating system installed on the server.
Preferred Contact Method
*
Phone
Phone
Email
Email
If EMR connected, what EMR are you connecting to?
Has your EMR provider been contacted to set up the interface?
Yes
Yes
No
No
Do you currently use and connect CardioPerfect to your EMR?
Yes
Yes
No
No
Is your EMR application installed on thick clients or accessed through RDP, Citrix XenApp, Citrix XenDesktop or other thin client? (If other, please state which.)
x