Clinic Name:
First Name:
Last Name:
Email Address:
Phone:
Are you currently using Custom Sound 6.1?
Is there a networked database within your office?
Do you have more than 1 computer running Custom Sound?
Do you have any satellite or affiliate offices associated with your clinic?
Are they connected to your networked Custom Sound database?
Is the database saved and backed-up on a regular basis?
Is the networked version of the Custom Sound database on a computer with 24/7 internet access?
What type of IT support do you have?
Name:
Email:
Phone:
Name:
Title:
Email:
Phone:
Do you need approval from a Legal department to move forward with the installation of Cochlear Link?
Legal Approval Date:
Do you need approval from an IT department to move forward with the installation of Cochlear Link?
IT Approval Date:
Are there any other departments that need to provide approval prior to the installation of Cochlear Link?
Contact Details:
Approval Date:
Contact Details:
Approval Date:
Contact Details:
Approval Date:
Is there any other information that is being requested from Cochlear?
Please describe. An email will be sent to a Cochlear representative who will assist you with any outstanding questions.
Are you currently enrolled in a clinical study with Cochlear?
Does Cochlear have permission to use the patient's MAPs through Cochlear Link while in the study?
What would you like to set as your clinic's Acceptable MAP Age (AMA)? (In other words, when are MAP's too old for Cochlear to use? The Default length is 2 years)
How many records do you currently have in your Custom Sound database?
Record Type ID (L):
Person Source:
Lead Source Detail:
GAClientID (C):
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13059 E Peakview Ave, Englewood, CO 80111, United States
