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) YES / NO

ORDER DETAILS
Name: Position: Email: Address:

Please complete with your details

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

Please return your completed order to:

orders@choiceandmedication.org.uk

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.
i)

ANNUAL CONTENT SUBSCRIPTION AGREEMENT

Annual subscription cost per NHS Trust (1,255 for 600k population) Population Subscription Population Subscription Served (K) Costs () Served (K) Costs () 700 800 900 1000 1100 1200 1300 1,455 1,625 1,789 1,958 2,127 2,291 2,460 1400 1500 1600 1700 1800 1900 2000 2,629 2,793 2,962 3,131 3,295 3,465 3,634

ii)

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

3. 4.

ANNUAL PORTAL MAINTENANCE AGREEMENT

Bespoke Portal IT support & maintenance (from Year 2 onwards) 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