Life Systems International

For Life Support Plans Enrollment.

NOTE: Fields shaded in RED indicate required fields.

Contact Information
Hospital Name:
Address: (to ship loaner equipment)
City:		State:
Your Name:		Title:
Hospital Phone:		Email:
Department Head Name:		Title:

Biomed Engineer Name:

Serial Number:
(found on back of Central Station):

# of Telemetry Transmitters:

Frequency of each transmitter: (last five of the serial number on back of transmitter)
#01	#02	#03	#04

#05

#06

#07

#08

#09

#10

#11

#12

#13

#14

#15

#16

#17	#18	#19	#20
#21	#22	#23	#24

Frequency of each transmitter:
(last five of the serial number on back of transmitter)

Please list each number below separated by a comma:

Printer name & model

Shipping account #:

More Information