Author: Rebecca Oxley

GSF Digital Solutions Order Form
Please ensure that you fully complete the form and return to the GSF Centre (primarycare@gsfcentre.co.uk)

1	Name and contact details of individual commissioning the programme:	Name	Tel No	Email
2	Do you have a local GSF Facilitator?	Name	Tel No	Email
3	Please list the practices that you would like to include in the below, giving the name of the GP system (EMIS Web, Vision, TPP SystemOne, EMIS LV, …) and a contact who deals with IT issues for the practice
	Practice Name + GP information system	Contact Name	Contact Tel No	Email
4	When do you plan to start the programme?
5	Programme Type	Cost	Number of practices	Total cost
	[1] GSF Digital Stage 1: for upto 20 practices with central IT and GSF support	£3000
	[2] GSF Digital Stage 2: for upto 20 practices with central IT and GSF support	£6000
	[3] GSF Digital Stage 3: Call for pricing	TBC
	Total / All costs are subject to the addition of VAT	£		£
6	Please provide the following invoicing details: / 1) Organisation and Address for invoicing purposes including payable reference / 2) Your Purchase Order Number / 3) Contact Name, Tel No. and Email Address for invoice:
7	On receipt of the fully completed form GSF will: / · Raise an invoice (payment is due on receipt) / · Send a contract for signature; once signed please return to The GSF Centre for countersigning. A copy of the contract will then be sent for your records. / · Payment must be received prior to the training packages being despatched. / Signed ____________________________________ / Date____________________________

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