ResMed

ResMed Sleep & Ventilation Program (RSVP)

VPAP Tx EQUIPMENT RENTAL FORM - USA

  If your purchase order number has an expiration date, please specify:*

To place an order, you must ensure this form is completed in its entirety. Please complete one form per installation address

Purchase Order

Does your facility require a Purchase Order Number for payment?

Yes No


If Yes, order will not be processed until an open-ended Purchase Order number is given
  Open-ended Purchase Order Number:*
Account Information


  Account Name:*
  Account Number:*
  Billing Address:
  City:*
  State:*
  Zip/Postal Code:*
Is shipping address same as billing address?  Yes No

  Shipping Address:*
  City:*
  State:*
  Zip/Postal Code:*
  Telephone:*
  
  Fax:*
  Total number of beds:*
  Account Type:*
Territory Manager information


  Name of territory manager:*
  Telephone:*
  
  Email address:*
Key Business Contact for your lab


  First Name:*
  Last Name:*
  Title:*
  Telephone:*
  
The email address entered here will receive a confirmation of the RSVP order form.
  Email:*
  Please confirm email address:*
  Best time of day to contact:*
IT/BioMed Support

Is IT required to install software and hardware?  Yes No
  What IT support does the lab have?*
IT Support Contact:
  Contact Name:*
  Title:*
  Telephone:*
  
  Email address:*
Is BioMed support required to install software and hardware?  Yes No
BioMed Contact:
  Contact Name:*
  Title:*
  Telephone:*
  
  Email address:*
Installation Information

Is installation address same as shipping address?  Yes No
  Installation Address:*
  City:*
  State:*
  Zip/Postal Code:*
Is Installation contact same as?
Key Business contact IT contact BioMed contact Other
  Contact Name:*
  Job Title:*
  Telephone:*
  Email address:*
  Best time of day to contact:*
  Additional Notes:*
  Is special access required?*
  If special access is required please explain:*
Pre-Installation Questions


  How many PCs will be receiving the new titration software?*
  Is there an existing network between PCs in the control room?*
  Do the control room PCs have internet access?*
  Will any PCs control more than one clinical titration system?*
  If yes, how many PCs? Specify quantity:
Does CAT 5 cabling exist for titration system on the following beds?

Answer only for the number of beds you have.
  Bed 1:*
Yes  No  N/A  
  Bed 2:*
Yes  No  N/A  
  Bed 3:*
Yes  No  N/A  
  Bed 4:*
Yes  No  N/A  
  Bed 5:*
Yes  No  N/A  
  Bed 6:*
Yes  No  N/A  
  Bed 7:*
Yes  No  N/A  
  Bed 8:*
Yes  No  N/A  
  Bed 9:*
Yes  No  N/A  
  Bed 10:*
Yes  No  N/A  
  Bed 11:*
Yes  No  N/A  
  Bed 12:*
Yes  No  N/A  
  Bed 13:*
Yes  No  N/A  
  Bed 14:*
Yes  No  N/A  
  Bed 15:*
Yes  No  N/A  
  Bed 16:*
Yes  No  N/A  
Clinical Rental Systems


  Quantity of VPAP Tx Clinical Systems ordered:*
Rental Equipment


  ApneaLink™ (P/N 22302)*
  ApneaLink™ Plus Complete Set - with Oximetry (P/N 22328)*
  ApneaLink™ Plus Basic Set - without Oximetry (P/N 22319)*
  ApneaLink™ Oximetry Accessories Kit (P/N 22304)*
  PSG-3 ResControl II (P/N 22011)*
  PSG-7 ResControl II (P/N 22007)*
  VPAP ST (P/N 26110)*
  VPAP Adapt SV (P/N 26013)*
  VPAP Auto 25 (P/N 26101)*
  S9 AutoSet™ (P/N 36005)*
  H5i™ with standard water chamber (P/N 36900)*
  H5i™ with cleanable water chamber (P/N 36901)*
  H4i™ with standard water chamber (P/N 26940)*
  HumidAire 2i™ (P/N 30902)*
Equipment/Supplies for Purchase


  H4i Water Chamber Kit - disposable; compatible with 26940 (P/N 26959)*
  VPAP Adapt SV Air Inlet Filter - Standard (3 pack) (P/N 26926)
PSG Brand

Indicate number of clinical systems to be set up with each brand of PSG System
  Alice:*
  Biologic:*
  Cadwell:*
  CNS (Aequitron):*
  Compumedics:*
  Embla (Rembrandt, Somnologica, RemLogic):*
  Grass:*
  NeuroVirtual:*
  Nihon Kohden:*
  Sandman:*
  SomnoStar:*
  Stellate:*
  Telediagnostics:*
  XLTEK:*
  If other, please specify brand name:*
  If other, please specify quantity:*
  DC Connector Type:
  Location of DC Box:
  Additional comments:
 
 
ResMed Corp | 9001 Spectrum Center Blvd., San Diego, CA 92123 | (800) 424-0737 | www.resmed.com