Thank you for your interest in Aspyra product solutions. In order for Aspyra to provide you with a budgetary quote, please fill out and submit the following questionnaire. You may also download a PDF version that you can print and return by fax.
Facility / Organization Name
Main Phone
Street Address
FAX phone
City, State, & ZIP
Website
Fiscal Year
Affiliation
Contacts - Title/Name Voice Phone / FAX Phone E-mail Address

If Other, please specify here:  
Hours of Operation
Multi-Site facilities?
 If Yes, number of facilities:
Office/Clerical Only: 
Performing/Imaging Locations:
Number of Physicians?  Number of Accessions or Exams per day?
I am interested in receiving a budgetary quotation for the following Aspyra solution(s):
Are you currently looking to replace an existing system?
If Yes, what is the name of your current vendor and product? 
Responses to the following questions will help us to provide you with a quotation that will best fit the needs of your organization.
List the major concerns or priorities you have with purchasing a new system.
 

What is your timeframe for acquiring a new system?

Average growth rate over the next few years:

How many years of data do you want to store online?

The budget allocated for the system is: 


How many modalities do you have?

Number of workstations needed? Clinical Diagnostic

How many radiologists will be viewing and reading images?



How many users will need to access the system concurrently? 

How many instruments are to be interfaced to the LIS? 

Will you be performing Microbiology via LIS?

Do you want to offer your physicians secure web access to input Orders and to access patient Results?


Would you like to schedule a demonstration of the Aspyra solutions? 

Person submitting form
Name
Phone
E-mail