Contract Consulting Service Request Form

In order for us to provide you with a quote for our Contract Consulting Service, please complete the form below.

Please provide the following contact information:

Salutation Please choose Mr. Ms. Mrs.

First name

Last name

Title

Organization

Street Address

Street Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Mobile Phone

FAX

Email

Client/Institution Name

Cerner Client Mnemonic

Cerner Client Number

Cerner Site/Project Contact Name

Cerner Site/Project Contact Telephone

Cerner Site/Project Contact Mobile Phone

Cerner Site/Project Contact Email

Please check the Cerner Platform in use:

Millennium

Classic 3.06

Classic 3.05

Classic 3.04

Please check the Operating System in use:

Open VMS

AIX

Other

What is the projected duration of this consulting engagement?

Please describe the consulting services you need in as much detail as possible:

Are there any special or unusual considerations?

Yes

No

If yes, please describe:

Will this project include...:

System Analysis

Troubleshoot Existing Programs

Interactive Programs (requiring user-interaction)

Programs to Run Automatically (from operations, etc.)

Custom Tables

Client Training or Education

PCG Help Service

Can you provide samples of the desired output for any required programs?

Yes

No