Triage^® Meter Software Registration

INSTITUTION INFORMATION
*Hospital Name:
Address:
*City:
*State or Province:
Zip or Postal Code:
Country:
METER INFORMATION
*Software Version:
*Meter Serial Number:	(Multiple meter entries can be separated by a comma.)
Date Installed:	Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
INSTALLER INFORMATION
*First Name:
*Last Name:
*Title:
*Email Address:
INSTALLATION DIAGNOSTICS
	Installation Successful? YesNo
	Meter Turned Off/On and System Test Successful? YesNo
	QC Simulator Run Successful? YesNo
INSTALLATION SURVEY
	The Triage MeterPlus has the capability to add a barcode scanner for the reading of User and Patient ID barcodes. Would you like additional information regarding this feature? YesNo
	Would you be interested in participating in brief written surveys regarding product features and designs? YesNo
	If future software upgrades were available via the internet, would you have access to a PC with internet capability that could also be connected to a meter? YesNo