OpenBiome | Partner Registration Form *THIS IS NOT AN ORDER FORM. Registration Information A. HOSPITAL / CLINIC INFORMATION 1. Name of hospital or clinic B. SHIPPING INFORMATION C. BILLING INFORMATION Provide specific details regarding where to send your shipment. Check if billing information is the same as shipping information 2. (ATTN) 10. (ATTN) 3. Company Name 11. Company Name 4. Street Address 12. Street Address 5. City 6. State 7. Zip code 13. City 8. Shipping contact phone number 16. Billing contact phone number 9. Shipping contact email address 17. Billing contact email address 14. State 15. Zip code D. OTHER COMMENTS OR SPECIAL INSTRUCTIONS Adverse Event Information We require two points of contact for any adverse event communication and coordination. E. ADVERSE EVENT CONTACT #1 F. ADVERSE EVENT CONTACT #2 18. Name 21. Name 19. Phone number 22. Phone number 20. Email address 23. Email address Material Tracking Logs Contact OpenBiome provides Material Tracking Logs with each shipment, which are a vital component of our quality assurance program and must be returned prior to placing future orders. We require one contact responsible for returning these Logs. G. TRACKING LOGS CONTACT 24. Name 25. Phone number 26. Email address Page 1 of 2 Rev Oct 2014 196 Boston Avenue Suite 1000 Medford, MA 02155 Phone: 617 575 2201 Fax: 617 575 2201 E-Mail: [email protected] Web: www.openbiome.org General Information & Policies Price List: UNITID FMP250 FMP30 DESCRIPTION 250 mL Fecal Microbiota Preparation for lower delivery (colonoscopy / enema) 30 mL Fecal Microbiota Preparation for upper delivery (NG / ND tube) Ordering: Submit OpenBiome Order Form, self-generated Purchase Order, or order details by email to [email protected] (preferred) or by fax to 617-575-2201 US Shipping Policy: Orders are processed and delivered within 5 business days. Buyer will cover the $250 cost of shipping and handling (S&H) per shipment. OpenBiome will cover S&H for orders of 15 units or more. Storing multiple units at your facility is the best way to ensure availability for immediate use and reduce shipping fees. Safety Policy: All clinicians using OpenBiome material will review the SAFE Protocol and Adverse Event Decision Algorithm available online at www.openbiome.org/safety and provided with each shipment. Should an adverse event occur, a clinician will notify OpenBiome within 24 hours. Usage Policy: OpenBiome material is for clinical use only, in accordance with FDA guidelines. Not for resale. ______________________________________________________ Signature of authorized hospital / clinic representative UNIT PRICE $250 $250 Initials _______________________________________________ Date ______________________________________________________ Printed name and title Page 2 of 2 Rev Oct 2014 196 Boston Avenue Suite 1000 Medford, MA 02155 Phone: 617 575 2201 Fax: 617 575 2201 E-Mail: [email protected] Web: www.openbiome.org