Choice And Medication Order Form

BESPOKE SUBSCRIPTION ORDER FORM 2012 I would like to order my customised subscription to Choice and Medication I agree to the terms and conditions supplied (delete)

ORDER DETAILS

YES / NO

Please complete with your details

Name: Position: Email: Address:

Email: Telephone: Fax No:

ORGANISATION Name: Trust Population: No of Pharmacies/Units: Purchase Order Number: Invoice To Accounts Payable Details:

I.T. DEPARTMENT Key Contact Name: Email: Telephone Number:

COMMUNICATIONS Key Contact Name: Email: Telephone Number:

Your required bespoke subscription package details: (cost overleaf) 1. 2. 3.

Front Page Portal Option A Front Page Portal Option B Front Page Portal Option C

Please return your completed order to:

YES / NO (delete as appropriate) YES / NO (delete as appropriate) YES / NO (delete as appropriate)

[email protected]

SUBSCRIPTION PACKAGE DETAILS www.choiceandmedication.org  The Choice and Medication Website is a product of Mistura Enterprise Limited Company Registration Number: 7012554 Registered Office: Arch Centre for Enterprise, Lintonville Parkway, Ashington, Northumberland, NE63 9JZ 

1. FRONT PAGE PORTAL DEVELOPMENT AND CONNECTION Bespoke Webpage (first year costs only) options A, B or C below: Includes first year annual portal maintenance charge OPTION DESCRIPTION COST A Small right hand side logo Free of Charge B Standard header package £1,127.50 C Full bespoke colour palate branding package £1,998.75 Package A will incur a connection fee of £563.75 which is included within package B & C

2.

ANNUAL CONTENT SUBSCRIPTION AGREEMENT

i)

Annual subscription cost per NHS Trust (£1,255 for 600k population) Population Subscription Population Subscription Served (K) Costs (£) Served (K) Costs (£) 700

1,455

1400

2,629

800

1,625

1500

2,793

900

1,789

1600

2,962

1000

1,958

1700

3,131

1100

2,127

1800

3,295

1200

2,291

1900

3,465

1300

2,460

2000

3,634

ii)

Annual subscription cost per Private Provider / Community Pharmacy : To be confirmed direct

3.

ANNUAL PORTAL MAINTENANCE AGREEMENT Bespoke Portal IT support & maintenance (from Year 2 onwards)

4.

£525

ADMINISTRATION REPORTING REQUIREMENTS Summary Dashboard Statistics [SDS} (One per annum at end of subscription) Free of Charge Analytics Comprehensive Report [ACR] (One per annum at end of subscription) Free of Charge Type Dashboard Statistics SDS Comprehensive ACR NB:

Frequency Single (Ad hoc) Quarterly (3 reports) Annually (11 reports) Single (Ad hoc) Quarterly (3 reports

Cost (£) 25 65 200 250 600

All package prices shown exclude VAT

www.choiceandmedication.org  The Choice and Medication Website is a product of Mistura Enterprise Limited Company Registration Number: 7012554 Registered Office: Arch Centre for Enterprise, Lintonville Parkway, Ashington, Northumberland, NE63 9JZ