Opportunity Registration Form

Partner information

Your full name *

Your email address *

Prospect information

Prospect’s company name *

Prospect's company website *

Organization Type *

Prospect's first name *

Prospect's last name *

Prospect's title *

Prospect's email address *

Opportunity description:

Country *

Use cases *

Lead generation / Marketing

Patient triage

Patient intake

Doctor decision support

Risk assessment / prescreening

Standardize process

Other

Use case detailed description

Infermedica's product *

Scope of services to be delivered to prospect by Partner *

Potential annual total deal value (USD) *

Target close date *

Expected go-live date

Opportunity description and other details *

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You can withdraw your consent at any time. Data from the form will only be used to fulfill the purpose of the marked checkboxes above. The Controller of your data is Infermedica Sp. z o.o. (Plac Solny 14/3, 50-062 Wrocław, Poland, office@infermedica.com). For more information on data processing, please review our Privacy Policy or contact our data protection officer (dpo@infermedica.com).

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