Services Order Form

TeleScan services order form

General Information:

Customer Name

First Name

Last Name

Customer Contact

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Customer Billing Contact

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Special Billing Instructions

TeleScan Subscription Ordered:

Location Size

Sonographer Days per Week

Average Scan Volume per Month for TeleScan

Initial Subscription Term

Subscription Commencement Date

YYYY

Monthly Subscription Fee

Additional Services Ordered:

Additional Services - Implementation Services

Staffing Augmentation Services

Minimum Days Notice for Services

Location Size

Fast Start Fees / Implementation Services Fees

Staffing Augmentation Fees

Total

I have read and agree to the Terms and Conditions. Link below.

I have read and agree to the Business Associate Agreement. Link below.

Customer’s signature below constitutes the placement of an Order with TeleScan, Inc., a Delaware corporation (“Company”), is subject to Company’s General Terms and Conditions for TeleScan Software as a Service (SaaS), located at www.telescan.ai/terms (as may be amended as described therein, the “Terms”), and includes and incorporates such Terms. In addition any provisions set forth on Schedule 1 attached to this Order (if any) shall also be incorporated herein. Capitalized terms used but not defined herein shall have the meaning ascribed to them in the Terms. In the event of a conflict between the Terms and the terms of this Order, the Order shall control. Further, by signing below, Customer and Company agree that they have entered into Company’s form Business Associate Agreement, a copy of which is located at www.telescan.ai/baa. Customer represents and warrants that it has been provided copies of and reviewed all terms, conditions and policies referenced herein whether by URL or otherwise.