Institution Name* 

Address 1*           

Address 2           

Suite #/ Dept     

City*     State*     Zip* 

Phone*     Fax     email* 

Responsible party for demo of ‘scripts *

Best way to contact this Person select one Email phone fax mail

Type of Institution* select one Hospital Out-Patient Clinic other

if other 

if other: criteria for measuring education needs

Size of Institution:

Staff size 

Number of Beds 

Number of out-patient visits per month 

Is the institution a specialty site?  Select one Yes No

if yes, what are the area(s) of Specialty?

COPYRIGHTS AND LIMITATIONS ON USE OF DEMO
     The information available through ‘SCRIPTS and all other intellectual property rights in the programs and data are the property of P&H and are protected by copyright and other intellectual property laws. Subscriber acquires no right, title, or license in the content or data incorporated in the ‘SCRIPTS application. P&H may at any time exercise editorial control over any content distributed through ‘SCRIPTS. This DEMO does not constitute the sale of ‘SCRIPTS or any copies thereof. The information available through ‘SCRIPTS is intended for reviewing and/or printing from a personal computer for the sole purpose of education about medical conditions, diagnoses, treatments, and self-care. ‘SCRIPTS information may not otherwise be edited, modified, translated to a foreign language, reproduced, retransmitted, stored, distributed, sublicensed, disseminated, sold, published, broadcast or circulated in any medium to anyone, including but not limited to others in the same company or organization, without the express prior written permission of P&H, except as otherwise expressly permitted under fair use provisions of U.S. Copyright Law. Upon expiration or termination of this DEMO, Subscriber shall have no further right to use or incorporate any content from ‘SCRIPTS in any manner whatsoever including, but not limited to, in any future health services or products it creates or sells.

Do you agree to abide by the above copyright restrictions and limitations
on use while using the Demo Module of ‘SCRIPTS from Pritchett & Hull?* Select one Yes No

Completed By*

Title               

In lieu of a signature, we require a unique identifier used only for 'scripts demo subscription verification purposes.
Please enter your initials*