Healthcare - EnCompass Setup Form

Please Note:

This form has been updated to include baseline setup requests. Please allow 48 hrs for processing.
Please do not continue to use the "ecolabdemo" EnCompass username to record baseline audits. You must fill out this form to ensure your customer is setup properly. That username is for customer demonstration and training purposes only.

ACCOUNT EXECUTIVE INFORMATION

Date *

Your Name: *

Your Email Address: *

PROGRAM INFORMATION

Select Program: *

HHOT Pricing Estimate Tool

OR Select Type: *

Baseline

Full Install

Central Sterile Select Type: *

Trial

Full Install

Module Selection: *

CSP Only

CSP DAZO Monitoring Only

CSP + CSP DAZO Monitoring

PR Select Type: *

Baseline

Full Install - DAZO Monitoring Only

Full Install - Base

Requires approval from marketing.

ASC Type: *

Trial

Full Install

CUSTOMER INFORMATION

Account Number
A valid acct. # is important as it drives the "View-As" functionality in the portal. You will not be able to see your customer's data without one
*

Customer Name *

Health System

Street Address *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Primary Contact Name *

Primary Contact's Email Address *

Contact Title *

Facility Bed Size *

Facility Annual Surgeries *

Please Select the Customer Type *

Ecolab Chemistry Customer R12 Sales > $2k

Non-Ecolab Chemistry Customer / Ecolab Chemistry Customer R12 Sales < $2k

# of Total Washers (Washer Disinfectors + Ultrasonic Washers) *

# of Ultrasonic Washers (if any)