Help Service Request Form

In order for us to provide you with a quote for our Help 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

For what time period do you want the Help Service to be available?

3 months

6 months

12 months

Please estimate the number of calls or emails to PCG that you anticipate per month:

1-15 calls per month

16-30 calls per month

31-45 calls per month

46 calls or more per month

What types of PCG Help will you need?

Answers to Questions about CCL

Answers to questions about CCL

Assistance in planning and designing CCL programs

System Analysis

Troubleshooting existing CCL programs

Other

Are there any special or unusual considerations?

Yes

No

If yes, please describe: