Hill-Rom e-Learning Course Form

Hill-Rom e-Learning Course
Simply fill out the form below to order your e-Learning course distributed through Healthstream.

All fields required.

Facility:

e-Learning / Healthstream Contact:

First Name:

Last Name:

Email:

Phone:

Example: xxx-xxx-xxxx

Address:

City:

State:

Country / Region:

Zip:

Hill-Rom Sales Reps:

Which course would you like to order: (select multiple if desired)

Yes	No
		Advanta™ 2 Med-Surg Bed
		Affinity® 4 Course
		CareAssist Course
		Clinitron Bed Course
		TotalCare® Bariatric Plus (Classic) eLearning Course
		TotalCare® Connect Bed and TotalCare® Bariatric Plus Connect e-Learning Course
		TotalCare® Bed (classic) e-Learning Course
Yes	No
		Are you already a Healthstream customer?
		If you are not a Healthstream customer, do you have a Learning Management System (LMS)?

If yes, please provide the following information:

LMS Name:

IT Contact:

First:

Last:

Email:

Phone: