VPAP Tx RSVP - Install form

ResMed Sleep & Ventilation Program (RSVP)

S9 VPAP™ Tx equipment install form

RSVP order information

Please indicate the Status of your device(s) below and, if prompted, provide your RSVP Case Number. If you do not have an RSVP Case Number, please enter the Device Serial Number (DSN) for each device. You can enter up to 5 DSNs

Case Device Status (Choose one, encouraged but not required)

Install information

Account number

Account name * required

Install address * required

City * required

State * required

Zip code: * required

Key contact for installation

Key contact first name * required

Key contact last name * required

Title: * required

Email * required

Phone number * required

Fax:

IT support contact

IT contact first name * required

IT contact last name * required

Title: * required

Email * required

Phone number * required

Special Access Required * Yes Norequired

Do the Control Room PCs have internet access? *

Yes Norequired

Is there a PSG system currently installed for each S9 VPAP Tx titration bed?

Yes No

For each bed that the S9 VPAP Tx Clinical System(s) will be installed on, is there a separate CAT5 cabling for each device?

Yes No

Do you have the permissions and the ability to install software?

Yes No

Is there an Admin login for use during installation?

Yes No

Are you on a domain or network group?

Yes No

What is the primary titration system being replaced? * required

What is the primary PSG system at the install location? * required

S9 VPAP Tx Clinical Systems	Part #	Quarterly Rent Payment
NEW INSTALL* S9 VPAP Tx Clinical System	36000	required
UPGRADE INSTALL* S9 VPAP Tx Clinical System	36050	required
Tx Link	25101	required
You authorize ResMed to return order/RMA all VPAP Tx devices being upgraded *Cost of installation is included in the rental fee
Total Payment Per Quarter — S9 VPAP Tx Clinical Systems

S9 VPAP Tx Clinical Systems	Part #	Price Per Unit
NEW INSTALL* S9 VPAP Tx Clinical System	36000	required
UPGRADE INSTALL* S9 VPAP Tx Clinical System	36050	required
Tx Link	25101	required
You authorize ResMed to return order/RMA all VPAP Tx devices being upgraded. *Cost of installation is included in the fee
Total — S9 VPAP Tx Clinical Systems

PSG system contact first name * required

PSG system contact last name * required

PSG system contact email * required

PSG system contact phone * required

Please enter your ResMed rep email address

Notes

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