* 1. What form of follow-up do you require? ---Please choose--- Sales representative to call Price Quote/Demo Literature only * 2. What is your timeframe for purchase? ---Please choose--- Urgent 0-6 months 6-12 months 12+ months * 3. Is this project funded? ---Please choose--- Yes Budgeted Not Budgeted Prepared to Submit Submitted Unsure
* 4. Would you like to become an ICAA member? ---Please choose--- Yes No
* 5. Would you like to hear more about Philips Healthcare Products and Services? ---Please choose--- Yes No