ER Express Client Invoicing Request
Please fill in this form so we can generate accurate invoices for you
Customer Information
Customer Name
*
Legal name of entity as it should appear on the invoice
*
Tax ID #
*
W9 (upload completed file here)
Invoicing Information
To whose attention should the invoice be addressed?
*
First Name
Last Name
Do have PO #s you want to appear on the invoice?
*
Yes, we have a PO # (or #s)
No, we do not have a PO #
Enter the PO #(s), if want us to put them on the invoice.
How would you like to receive invoices (you can choose more than one)?
*
By email
By mail
Passenger pigeon (just kidding)
Invoicing Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Address to which invoices should be emailed
*
Point of Contact (in case we have questions about this form)
Your name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Submit
Client ID Profile (completed by ER Express)
Client ID Profile (to be completed by ER Express)
Which products are this client using?
Check-in Express
ER Passport
Text-in Express
Feedback Express
Aftercare Express
Wellness Express
Patient Experience Tablet
What type of customer is this?
Emergency Department
Standalone ED
Urgent Care
ED and Urgent Care
Multi-campus or single campus?
Single campus
Multi-campus
Enter the parent facility name and client ID #
Enter the child facility names and client IDs
Is there a free trial period?
Yes
No
How long is the free trial (in months)?
What kind of free trial?
Waived payment - client does not have to pay for free period at all
Deferred payment - client pays up if they continue
Is the invoicing schedule simple or complex?
Simple
Complex
If the invoicing schedule is complex, upload supporting file here
Number of paying facilities
Set-up fees
Subscription fees per facility per month
Term (# of subscription months)
Monthly Invoice Amount
Billing should start on:
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2016
2015
2014
Year
Line Item Notes for Accounting
This form is approved and ready for invoicing to begin
Approved
Submit
Draft Invoice for Review (to be completed by accounting)
Upload the draft invoice in word doc format
Enter your e-mail
This invoice is ready for Sahil to review
Ready for review
Submit
Invoice approval / revision (to be completed by Sahil)
Is this invoice ready to send to the cilent?
Yes, it is approved and ready to send
No, it needs revisions
Enter revision notes
Upload revised file here
Submit
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