Repleni-Trac™

Repleni-Trac™

Order Verification Form
Account Number
Legal Entity Name
Is this request to add locations to the existing RTV contract?
Responsible Party Information
Name
Title
Phone Number
Email Address
TSS Email Address
Sales Director Email Address
Approving TM Email Address
- Large vault - 24" H x 14" D x 14" W (109 lbs)
- Small vault - 15" H x 14" D x 14" W (72 lbs)
- Location 1 Details
- Account Number
- TM Email Address
- TM Region
- Requested Install Date
  
  MonthDayYear
  Date
- PIMS
- Current AllyDVM User?
- Account Name
  DBA Name
- Contact Name
- Contact Phone Number
- Contact Email Address
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Kiosks
- First Kiosk
- Additional Kiosk Quantity
- Vaults
  
  Indicate quantity of each vault needed.
- 15"H x 14"D x 14"W (72lbs)
- 24"H x 14"D x 14"W (109lbs)
- 10"x16"x24" (V5a)
- 15"x16"x24" (V5b)
- You must select at least 1 vault.
- AddKioskMonthly
- TotalVaults
- VaultsMonthly
- TotalMonthly
- Site Setup & Installation - $1,499.00
  
  Monthly Cost - {Loc1TotalMonthly}
- Location 2 Details
- Account Number
- TM Email Address
- TM Region
- Requested Install Date
  
  MonthDayYear
  Date
- PIMS
- Current AllyDVM User?
- Account Name
  DBA Name
- Contact Name
- Contact Phone Number
- Contact Email Address
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Kiosks
- First Kiosk
- Additional Kiosk Quantity
- Vaults
  
  Indicate quantity of each vault needed.
- 15"H x 14"D x 14"W (72lbs)
- 24"H x 14"D x 14"W (109lbs)
- 10"x16"x24" (V5a)
- 15"x16"x24" (V5b)
- You must select at least 1 vault.
- AddKioskMonthly
- TotalVaults
- Loc2Install
- Loc2KioskOne
- VaultsMonthly
- TotalMonthly
- Site Setup & Installation - $1,499.00
  
  Monthly Cost - {Loc2TotalMonthly}
- Location 3 Details
- Account Number
- TM Email Address
- TM Region
- Requested Install Date
  
  MonthDayYear
  Date
- PIMS
- Current AllyDVM User?
- Account Name
  DBA Name
- Contact Name
- Contact Phone Number
- Contact Email Address
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Kiosks
- First Kiosk
- Additional Kiosk Quantity
- Vaults
  
  Indicate quantity of each vault needed.
- 15"H x 14"D x 14"W (72lbs)
- 24"H x 14"D x 14"W (109lbs)
- 10"x16"x24" (V5a)
- 15"x16"x24" (V5b)
- You must select at least 1 vault.
- AddKioskMonthly
- TotalVaults
- Loc3Install
- Loc3KioskOne
- VaultsMonthly
- TotalMonthly
- Site Setup & Installation - $1,499.00
  
  Monthly Cost - {Loc3TotalMonthly}
- Location 4 Details
- Account Number
- TM Email Address
- TM Region
- Requested Install Date
  
  MonthDayYear
  Date
- PIMS
- Current AllyDVM User?
- Account Name
  DBA Name
- Contact Name
- Contact Phone Number
- Contact Email Address
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Kiosks
- First Kiosk
- Additional Kiosk Quantity
- Vaults
  
  Indicate quantity of each vault needed.
- 15"H x 14"D x 14"W (72lbs)
- 24"H x 14"D x 14"W (109lbs)
- 10"x16"x24" (V5a)
- 15"x16"x24" (V5b)
- You must select at least 1 vault.
- AddKioskMonthly
- TotalVaults
- Loc4Install
- Loc4KioskOne
- VaultsMonthly
- TotalMonthly
- Site Setup & Installation - $1,499.00
  
  Monthly Cost - {Loc4TotalMonthly}
- Location 5 Details
- Account Number
- TM Email Address
- TM Region
- Requested Install Date
  
  MonthDayYear
  Date
- PIMS
- Current AllyDVM User?
- Account Name
  DBA Name
- Contact Name
- Contact Phone Number
- Contact Email Address
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Kiosks
- First Kiosk
- Additional Kiosk Quantity
- Vaults
  
  Indicate quantity of each vault needed.
- 15"H x 14"D x 14"W (72lbs)
- 24"H x 14"D x 14"W (109lbs)
- 10"x16"x24" (V5a)
- 15"x16"x24" (V5b)
- You must select at least 1 vault.
- AddKioskMonthly
- TotalVaults
- Loc5Install
- Loc5KioskOne
- VaultsMonthly
- TotalMonthly
- Site Setup & Installation - $1,499.00
  
  Monthly Cost - {Loc5TotalMonthly}
- Leaving TM Approval as XXX will keep this JotForm in draft state.
  
  Providing TM Approval initials will move this to contracting with the customer.
- TM Approval
  Initials required to proceed. Keep XXX if not ready to move to contracting.
- Status
- Key
- Contract Effective Date
  
  MonthDayYear
  Date
- Location 1 Details
  
  Contact Name: {Loc1ContactName}
  
  Contact Phone Number: {Loc1ContactPhone}
  
  Contact Email Address: {Loc1ContactEmail}
  
  Contact Address: {Loc1address}
  
  Current AllyDVM User? {Loc1AllydvmUser}
- Secondary Contact Information
- Contact Name
- Phone Number
- Email Address
- Network Connection
- Previous process for managing inventory
- Most appealing Repleni-Trac feature?
- Reason & Current State
- Current System
  
  Other
- Logs
  
  Other
- PDMP
- Have you used PDMP in the past?
- Current confident - unauthorized
- Current system time - unauthorized
- Customer Time consuming
  
  Other
- Dispensing time
- Who maintains log books
  
  Other
- Important outcome
- Value the most
- Additional comments
- Kickoff Complete
  Initials of Implementer
- Should be Empty:

Repleni-Trac™

Responsible Party Information

Location 1 Details

Kiosks

Vaults

Location 2 Details

Kiosks

Vaults

Location 3 Details

Kiosks

Vaults

Location 4 Details

Kiosks

Vaults

Location 5 Details

Kiosks

Vaults

Secondary Contact Information