Connectivity IoT — Pre-Installation Report

Information collection for Fujifilm Connectivity (C-BOX) software licenses and related services. Fields marked with * are required.

1. Request type *

Select the option that best describes your request.

License Renewal Renew an existing Fujifilm Connectivity software license. New License Request a new Connectivity subscription for a site or customer. Equipment Integration Integrate additional IVD equipment with an existing C-BOX. New Development Request Request custom development or a non-standard integration scope.

2. Customer Identification

Customer Name * Hospital Name *

Installation Address

Country Department Expected Go-Live

3. Field Engineer responsible for installation

Name * E-mail *

Phone Company

4. IVD Equipment to be integrated with C-BOX

Note: maximum of 5 IVD equipment connections per Connectivity Box (recommended). The 6th slot should only be used with prior Fujifilm approval.

IVD Equipment #1

Brand Model

IVD Equipment #2

Brand Model

IVD Equipment #3

Brand Model

IVD Equipment #4

Brand Model

IVD Equipment #5

Brand Model

IVD Equipment #6 (exception)

Brand Model

5. Additional notes (optional)

Use this field to provide any extra context, special requirements or details about your request.

Observations

Details

By submitting, you confirm the accuracy of the information provided. This data will be used to generate a commercial proposal for the Fujifilm Connectivity Software subscription.