Information Request Form

Your Demographics

You would like CML to ...      Call you      Send you information electronically

You are currently...    gathering information evaluating specific systems looking to purchase in the next 6-12 months looking to purchase in the next 13-24 months


Activities of your organization:

Hemodialysis: number of Hemo Patients
Peritoneal dialysis: number of PD Patients
Hemodialysis machine types	Fresenius Cobe / Gambro Baxter/Althin Hospal Bellco Other...     Other:
Desired Links to Ancillary Systems	Laboratory Results ADT (patient demographics) Pharmacy Billing / Financial Radiology Laboratory Results ADT (patient demographics) Pharmacy Billing / Financial Radiology Laboratory Results ADT (patient demographics) Pharmacy Billing / Financial Radiology
Transplant Program	Yes    No

Organization
Your Name
Your Title
Address
City		State/Province
Country	Zip/Postal Code
Telephone	Fax
Email

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