Health Center Name
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Executive Director
|
Installation Site Name
|
Installation Site Address
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Installation Site City
|
Installation Site State
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Installation Site Zip
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Installation Site Phone Number * (Please include ext)
|
Site Contact Person First Name
|
Site Contact Person Last Name
|
Site Contact Email
|
Time Zone
|
Wall Composition
|
Ceiling Composition
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Access To Power Source- (Must be within 6 ft from Unit)
Power Source |
*Wireless Capability (Refers to the # of cell phone bars visible in your waiting area)
One
Two
Three
Four
Five |
Cellular Phone Provider
|
Spanish Content Needed
Yes
No |
Site Operating Hours and Days
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Preferred Installation Day
Monday
Tuesday
Wednesday
Thursday
Friday |
Do you anticipate a remodel, closure, or moving for the site in 6 months?
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