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Telemedicine

Request for Non-Clinical Videoconference

Rates

Technical Support:
$150/hour during regular business hours (08:00 - 18:00);
$200/hour after regular business hours (pending approval)

An additional flat fee of $50 applies for scheduling and coordination of multi-point events

*48 hours notice required for cancellations or fees may apply
*Organizer will be notified in advance of additional connection charges
*Rates subject to change and do not include HST

I agree to the above terms: Yes No

* = required

Primary Contact
Contact Name:*
Organization:*
Email:*
Telephone:*
Secondary Contact
Contact Name:
Organization:
Email:
Telephone:
Billing Details
Contact Name:*
Address:*
City:*
Postal Code:*
Email:*
Telephone:*
Event Details
Event Type:*	Education Administrative Other
Event Name:*
Speaker/Chair:*
Event Date:* (start date if recurring)
Start Time:*
Stop Time:*
If recurring, Additional Dates:
Host Site:*
Room Details
Estimated number of participants at SMH:*
Will there be a presentation from SMH (Powerpoint or other)?*	Yes No
Remote Site Information
Remote site locations (Please select all that apply):*	Ontario Outside Ontario Connections with sites outside of Ontario will be subject to additional charges. Quotations will be provided to the organizer for approval.
Webcasting
Is webcasting required?	Yes No NOTE: Webcast requests must be submitted at least 6 business days prior to the event. Archived webcasts will require a signed consent. Webcasts an be found at http://webcast.otn.ca
Additional Information

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