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First name
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Last name
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ORD #
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Hospital Name
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Hospital Delivery Address
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Hospital Department and Room Number/Location
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Primary Contact Phone and Email
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Secondary Contact Phone and Email
SMA White Glove PO # and Additional Notes/Dates
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De-install Notes: Plan for De-installed Equipment? Same Day installation? ETC. (Dashes to start Each Line Item)
Carrier Tracking #
Logiquip Tracking #
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Build Project Onsite or SMA
Onsite
SMA
Other
Estimated Product Delivery Date
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Where Onsite Will Product be Located? (Confirm With Customer)
Detail Required Start and End Times - Include Notes Per Day as Needed (Dashes to Start Each Line Item)
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PPE Required? Any Other Site-Specific Requirements?
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Explain Cart Buildout - Confirmation Call With Salesperson Will be Scheduled (Dashes to Start Each Line Item)
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Additional Project Notes Helpful for a Smooth and Successful Installation (Dashes to Start Each Line Item)
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