esubscription Facility Order Form

Transcription

1 Is this a renewal? Yes No FACILITY INFORMATION ADMINISTRATOR/CONTACT INFORMATION First Name: Last Name: Credentials: Title: Phone: ORDER DETAILS Choose one of the following 12-month subscription options: OPTION A: SINGLE SITE Please check the desired concurrency level (i.e., number of simultaneous users at a single site): up to 2 users -- $450 up to 5 users -- $845 up to 10 users -- $1,570 up to 25 users -- $2,955 OPTION B: MULTI-SITE Please check the desired number of facility sites: 2-9 sites -- $3, sites -- $7, sites -- $17, sites -- For pricing contact periopsolutions@aorn.org or call (800) Indicate your external IP address/address range: From To If you are purchasing an esubscription for the first time and are part of a health care network, please be sure to request a unique IP address or range from your IT department for your locations. If this is a renewal order you don t need to provide IP address information again. The following IP address ranges are not valid for esubscription: Print Book Additions Please add print copies of the Guidelines for Perioperative Practice to my order at member pricing ($215 ea). $6.95 for the first set, $.95 for each additional set. (Book orders shipping to California, Colorado, and Pennsylvania may be subject to state tax.) Contact AORN for international shipping costs. Book Qty: Shipping: $ Book Total: $ Total Amount Due: $ esubscription: Facilities: page 1 of 5

2 MULTI -SITE ADDITIONAL FACILITY INFORMATION (Attach additional pages if needed.) esubscription: Facilities: page 2 of 5

3 PAYMENT INFORMATION METHODS OF PAYMENT Option 1 Pay by Phone - your completed form to orders@aorn.org and call Customer Service at to pay by credit card. DO NOT complete page 5. Option 2 Pay by Fax - Complete the credit card payment form on page 5 and fax the complete form to Option 3 Pay by Mail - Send check or complete the credit card payment form on page 5 and mail complete form to 2170 South Parker Road, Suite 400, Attn: Orders. ORDER PROCESS 1. Complete order form and submit with payment to AORN (a purchase order is not considered payment). 2. Order will be processed and agreement activated after AORN receives both completed order form and payment. 3. Administrator(s)/contact will receive the registration . By signing or typing my name below, I agree to the AORN Terms and Conditions and the esubscription Agreement Conditions for this purchase and any future purchases. If the product purchased is for use by my facility, I am authorized by my facility to bind my facility to the terms of this agreement. Type or sign here: Date: MAIL OR FAX ORDER FORM: Attn: Orders 2170 S Parker Rd, Suite 300 Denver, CO Secure Fax: QUESTIONS? Contact Experience Services US Phone: International Phone: esubscription: Facilities: page 3 of 5

4 THIS PAGE INTENTIONALLY LEFT BLANK esubscription: Facilities: page 4 of 5

5 PLEASE DO NOT THIS SECTION BELOW CONTAINING CREDIT CARD DATA. sent with credit card numbers are not secure and will be automatically blocked. Only complete this section if you are sending via secure fax (Option 2) or by mail (Option 3). Credit Card Type: Visa MasterCard American Express Discover Credit Card Number: Expiration Date: CVV: Credit Card Holder Name: Signature: Purchasing Agent Name (if different from credit card holder): Purchasing Agent Address: Total Amount Paid $: Phone: MAIL OR FAX ORDER FORM: Attn: Orders 2170 S Parker Rd, Suite 300 Denver, CO Secure Fax: QUESTIONS? Contact Experience Services US Phone: International Phone: FOR OFFICE USE ONLY Version: Facility Name: Account #: esubscription: Facilities: page 5 of 5