InCenter Access Form

Customers with existing Support Agreements please complete the following information to obtain access to InCenter
* Indicates required field.

PERSONAL INFORMATION

* First Name
*Last Name
*Hospital/Clinic
*Address
*City
*State
*Post/Zip
Telephone
*Email

QUESTIONS

1. Contract Number (stated on Philips Quotation/PO)

2. Start Date

3. End Date

4. Type Of Equipment Covered
Patient Monitoring
IntelliSpace Event Management
Diagnostic ECG
Resuscitation

5. Number of site users determined by total contract value as follows
less than 10K = 1 user
more than 10K but less than 25K = 2 users
more than 25K but less than 100K= 5 users
more than 100K = unlimited
1 user
2 users
5 users
unlimited

6. User1 first name

7. User1 last name

8. User1 e-mail

9. User1 telephone

10. User2 first name

11. User2 last name

12. User2 e-mail

13. User2 telephone

14. User3 first name

15. User3 last name

16. User3 e-mail

17. User3 telephone

18. User4 first name

19. User4 last name

20. User4 e-mail

21. User4 telephone

22. User5 first name

23. User5 last name

24. User5 e-mail

25. User5 telephone

Submit
Clear