Project Profile The information you provide in this form will allow us to prepare a cost analysis for your project. Please be as accurate as possible so we may provide you with the best possible scenario. The prices you receive in your investment analysis are valid for 30 days from the date of preparation. All information provided is kept confidential and is not shared with any outside source besides agreed IT partners. Practice/hospital name: City/State/ZIP: Email: Completed by:
Address: Phone: Contact: Date:
Please return by fax or email to:
ifa systems AG Fax +49-2234-9336730 Email info@ifasystems.com
_______________________________________________________________________________________
In order to be able to calculate the number of licenses needed in your office, please provide us with the following information: # of PCs currently in use (incl. front desk, back office and examination lanes) # of exam rooms (1 license per exam room) # of pre-screening/tech/photo rooms (1 PC is needed to connect the instruments. Depending on the number and type of instruments, more than one PC may be needed per room.) # check-in and check-out areas (1 license per area) # staff in back office (e.g. billing and scribes)? # other medical staff Name(s)/types of software currently used (e.g. practice management, billing software etc.): __________________________________ ________________________________ Please list the quantity and manufacturer of all diagnostic instrumentation in the practice/hospital: Instrument
Qty.
Manufacturer
Instrument
Lensmeter
Fundus camera
Autorefractor
HRT/LDT/OIS/ImageNet
Autokeratometer
Endo camera
NCT
A-Scan
Computer phoropter
B-Scan
Perimeter
Corneal topog.
Qty.
Manufacturer
Photo slit lamp
ifa systems AG www.ifasystems.com
Phone: +49-2234-933670 Fax: +49-2234-9336730