Executive VIP Program request form Account Name *Account External ID: *About the Account: *Account Type: *About the Executive Attendees: *(List each and title)About the Surgeon Attendees: *(List each and title)Hospital Vision: *Hospital Mission: *Da Vinci Background: *Visit Goals: *Sales Goals: *Discussion Topics (Check all that apply) *ThoracicGeneral SurgeryColorectalGYNUrologyXiFuture TechAdvanced InstrumentationHealthcare EconAcademicsTrainingResearchManufacturing TourMaintenance Contracts & Service OfferingsCustomer Portal DemoOtherGoals for each topic checked: *How are we measuring the ROI of this visit: *Account Report Card: *(Attach report card)RemoveSurgeon Report Card: *(Attach report card)RemoveSystem Purchase Potential: Y/N *YesNoPrimary Sales Host: *Secondary Sales Host: *Date Requested for VIP Visit: *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year204020392038203720362035203420332032203120302029202820272026202520242023Vice President Name: *(Attach VP approval)RemoveSubmit
