Creating the SignUp Page, Custom Form Instructions

• Please select all the text inside the box below, copy and paste, via the SOURCE tab , into a new custom page.
• You must name the page exactly RemoteGateway Signup.
• Click on the "Save Changes".
• Scroll down to the area at the bottom of your new form page that says "Place submit button here" and click to place your mouse cursor. (You may also erase this text) after the submit button is generated in the next step.
• Choose the toolbox option {} and chose an email recipient & submit option.

Any questions, please contact eHC Tech Support at 615-344-6179 or your friendly eHC Account Manager.

<DIV align=left><A href="CustomPage.asp?guidCustomContentID=328B4749-9844-4CEA-AEF7-C00D818CC4FA"><IMG title="Signup for Remote Gateway!" alt="Remote Gateway" src="http://inspiration.ehc.com/cpm/RG-longLogo.gif" border=0></A></DIV> <H4>Sign-up Requirements:</H4> <P> <UL><IMG hspace=5 src="http://inspiration.ehc.com/CPM/SecurID-softToken.gif" align=right vspace=5> <LI>SecurID Soft Token or Hard Token for authentication to the hospital network. <LI>Approved access to hospital clinical applications <LI>Administrative access rights to your computer (required only for the initial hookup.)</LI></UL></p> <TABLE cellPadding=5 width="100%" cellspacing=0> <TR vAlign=bottom> <TD> </TD> <TD><FONT face=Arial color=#ff0000 size=1>* Required Fields</FONT></TD></TR> <TR> <TD>First Name</TD> <TD><FONT face=Arial color=#ff0000 size=2><B>*</B></FONT> <INPUT id=Reqd-FirstName name=Reqd-FirstName></TD></TR> <TR> <TD>Last Name</TD> <TD><FONT face=Arial color=#ff0000 size=2><B>*</B></FONT> <INPUT id=Reqd-LastName size=10 name=Reqd-LastName></TD></TR> <TR> <TD>Practice Name</TD> <TD>  <INPUT size=10 name=PracticeName></TD></TR> <TR> <TD>Practice Street Address</TD> <TD>  <INPUT size=15 name=PracticeAddress> <TD></TD></TR> <TR> <TD>Practice City</TD> <TD>  <INPUT size=10 name=PracticeCity> <TD></TD></TR> <TR> <TD>Practice State</TD> <TD>  <SELECT size=1 name=PracticeState> <OPTION selected></OPTION> <OPTION value=AL>AL</OPTION> <OPTION value=AK>AK</OPTION> <OPTION value=AZ>AZ</OPTION> <OPTION value=AR>AR</OPTION> <OPTION value=CA>CA</OPTION> <OPTION value=CO>CO</OPTION> <OPTION value=CT>CT</OPTION> <OPTION value=DE>DE</OPTION> <OPTION value=FL>FL</OPTION> <OPTION value=GA>GA</OPTION> <OPTION value=HI>HI</OPTION> <OPTION value=ID>ID</OPTION> <OPTION value=IL>IL</OPTION> <OPTION value=IN>IN</OPTION> <OPTION value=IA>IA</OPTION> <OPTION value=KS>KS</OPTION> <OPTION value=KY>KY</OPTION> <OPTION value=LA>LA</OPTION> <OPTION value=ME>ME</OPTION> <OPTION value=MD>MD</OPTION> <OPTION value=MA>MA</OPTION> <OPTION value=MI>MI</OPTION> <OPTION value=MN>MN</OPTION> <OPTION value=MS>MS</OPTION> <OPTION value=MO>MO</OPTION> <OPTION value=MT>MT</OPTION> <OPTION value=NE>NE</OPTION> <OPTION value=NV>NV</OPTION> <OPTION value=NH>NH</OPTION> <OPTION value=NJ>NJ</OPTION> <OPTION value=NM>NM</OPTION> <OPTION value=NY>NY</OPTION> <OPTION value=NC>NC</OPTION> <OPTION value=ND>ND</OPTION> <OPTION value=OH>OH</OPTION> <OPTION value=OK>OK</OPTION> <OPTION value=OR>OR</OPTION> <OPTION value=PA>PA</OPTION> <OPTION value=RI>RI</OPTION> <OPTION value=SC>SC</OPTION> <OPTION value=SD>SD</OPTION> <OPTION value=TN>TN</OPTION> <OPTION value=TX>TX</OPTION> <OPTION value=UT>UT</OPTION> <OPTION value=VT>VT</OPTION> <OPTION value=VA>VA</OPTION> <OPTION value=WA>WA</OPTION> <OPTION value=WV>WV</OPTION> <OPTION value=WI>WI</OPTION> <OPTION value=WY>WY</OPTION></SELECT></TD> <TD></TD></TR> <TR> <TD>Phone Number</TD> <TD>  <INPUT id=Phone size=15 name=Phone></TD></TR> <TR> <TD>Email Address</TD> <TD><FONT face="Arial, Helvetica, sans-serif" color=#ff0000 size=2><B>*</B></FONT> <INPUT id=Reqd-emailAddress name=emailAddress></TD></TR> <TR> <TD></TD> <TD>Place submit button here.</TD></TR></TABLE>