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https://www.baxterglobal.com/FLC_Consent_Basic/
Submission: On February 17 via manual from BE — Scanned from DE
Submission: On February 17 via manual from BE — Scanned from DE
Form analysis
1 forms found in the DOMPOST /FLC_Consent_Basic/consent?vs=NzBlMjBmNjQtNWExYy00MzkyLTk3MzUtZWE4MWI5N2VkY2QzOzsS1
<form class="needs-validation" novalidate="" action="/FLC_Consent_Basic/consent?vs=NzBlMjBmNjQtNWExYy00MzkyLTk3MzUtZWE4MWI5N2VkY2QzOzsS1" method="post">
<div class="row">
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom02" class="font-weight-bold">First Name<font color="#F70211">*</font></label> <input type="text" placeholder="First Name" id="validationCustom02" class="form-control" name="FIRST_NAME"
required="" value="">
<div class="invalid-feedback">Please enter first name.</div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom03" class="font-weight-bold">Last Name<font color="#F70211">*</font></label> <input type="text" class="form-control" id="validationCustom03" placeholder="Last Name" value="" name="LAST_NAME"
required="">
<div class="invalid-feedback">Please provide a last name.</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom04" class="font-weight-bold">Email<font color="#F70211">*</font></label> <input type="text" placeholder="Email" id="validationCustom04" class="form-control" name="Email" required="" value="">
<div class="invalid-feedback">Please provide email</div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom05" class="font-weight-bold">Hospital<font color="#F70211">*</font></label> <input type="text" class="form-control" id="validationCustom05" placeholder="Hospital" name="INSTITUTION_NAME"
required="" value="">
<div class="invalid-feedback">Please provide hospital.</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom06" class="font-weight-bold">Function/Specialty<font color="#F70211">*</font></label> <select class="form-control" name="IBM_SPECIALITY" required="">
<option disabled="" value="" selected="">Select one...</option>
<option value="IT">IT</option>
<option value="Procurement">Procurement</option>
<option value="Nurses / Clinicians">Nurses / Clinicians</option>
<option value="Biomeds">Biomeds</option>
<option value="Other">Other</option>
</select>
<div class="invalid-feedback">Professional Designation</div>
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<div class="col-sm-6">
<div class="form-group"><label for="validationCustom07" class="font-weight-bold">Job Role<font color="#F70211">*</font></label> <select class="form-control" name="IBM_PROFESSIONAL_TYPE" required="">
<option disabled="" value="" selected="">Select one...</option>
<option value="Director of informatics">Director of informatics</option>
<option value="Informatics Manager">Informatics Manager</option>
<option value="Informatics Analyst">Informatics Analyst</option>
<option value="IT project Manager">IT project Manager</option>
<option value="Other IT">Other IT</option>
<option value="Head Buyer">Head Buyer</option>
<option value="Director of purchasing">Director of purchasing</option>
<option value="Purchasing / Contract Manager">Purchasing / Contract Manager</option>
<option value="Purchaser">Purchaser</option>
<option value="Other Procurement">Other Procurement</option>
<option value="CNIO - Chief Nurse Information Officer">CNIO - Chief Nurse Information Officer</option>
<option value="Head Nurse">Head Nurse</option>
<option value="Clinical Specialist (HCP)">Clinical Specialist (HCP)</option>
<option value="Nurse">Nurse</option>
<option value="Hygienist">Hygienist</option>
<option value="Clinical physicist">Clinical physicist</option>
<option value="Other Clinician">Other Clinician</option>
<option value="Chief Medical Technician ">Chief Medical Technician </option>
<option value="Biomed">Biomed</option>
<option value="Other Biomeds">Other Biomeds</option>
<option value="Other">Other</option>
</select>
<div class="invalid-feedback">Please select Profession/Specialty</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom08" class="font-weight-bold">City<font color="#F70211">*</font></label> <input type="text" class="form-control" id="validationCustom08" placeholder="City" value="" name="BILLING_CITY"
required="">
<div class="invalid-feedback">Please provide city.</div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom09" class="font-weight-bold">Country<font color="#F70211">*</font></label> <select class="form-control" name="COUNTRY" required="">
<option disabled="" value="" selected="">Choose Country...</option>
<option value="Belgium">Belgium</option>
<option value="Netherlands">Netherlands</option>
<option value="Sweden">Sweden</option>
</select>
<div class="invalid-feedback">Please select country</div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group"><label for="validationCustom10" class="font-weight-bold">Phone Number</label><input type="text" class="form-control" id="validationCustom10" placeholder="Phone" value="" name="PHONE"></div>
</div>
</div>
<div class="row">
<div class="hgt20"> </div>
<div class="col-sm-12"><label for="validationCustom11" style="font-weight:500 !important">What would you like further information on?</label></div>
<div class="hgt20"> </div>
<div class="col-sm-4">
<div class="mrgbtm10"><input type="checkbox" name="PREF_FLC" value="Yes"> FLC (Welch Allyn and Mortara products) </div>
</div>
<div class="col-sm-4">
<div class="mrgbtm10"><input type="checkbox" name="PREF_CARE_SOLUTIONS" value="Yes"> Care Solutions</div>
</div>
</div>
<div class="hgt20"> </div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="Yes" name="CONFIRMED_EMAIL_OPT_IN" required="" id="validationCustom12"> <label style="font-weight:500 !important" for="validationCustom12"> Yes, I confirm that I have
received the
<a href="https://www.baxterglobal.com/FLC_Consent_Basic/LPT.url?kn=918460&vs=NzBlMjBmNjQtNWExYy00MzkyLTk3MzUtZWE4MWI5N2VkY2QzOzsS1" style="color: #007bff; text-decoration: underline" target="_blank" xtlinkname="httpswwwbaxterglobalcomPrivacyNoticesPrivacy_notices" name="httpswwwbaxterglobalcomPrivacyNoticesPrivacy_notices" xthyperlink="918460">Privacy Notice</a>
<font color="#F70211">*</font>.
</label>
<div class="invalid-feedback">Please tick checkbox.</div>
</div>
<div class="hgt20"> </div>
<p>By clicking on the Submit button, you agree to receive from Hillrom electronic marketing communications about its products, services and events, as per its
<a href="https://www.baxterglobal.com/FLC_Consent_Basic/LPT.url?kn=918461&vs=NzBlMjBmNjQtNWExYy00MzkyLTk3MzUtZWE4MWI5N2VkY2QzOzsS1" style="color: #007bff; text-decoration: underline" target="_blank" xtlinkname="httpswwwbaxterglobalcomPrivacyNoticesPrivacy_notices" name="httpswwwbaxterglobalcomPrivacyNoticesPrivacy_notices" xthyperlink="918461">Privacy Notice</a>.
</p>
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id="date" name="PRIVACY_INFORM_DTE" value="02/17/2023"> <input name="OPT_OUT_REASON" value="Active" type="hidden"> <input type="hidden" id="date2" name="OPT_OUT_REASON_CHANGE_DATE" value="02/17/2023"> <input name="IBM_CONSENT_SENT" value="Yes"
type="hidden"> <input type="hidden" name="UTM_SOURCE" value=""> <input type="hidden" name="UTM_MEDIUM" value=""> <input type="hidden" name="UTM_CAMPAIGN" value=""> <input type="hidden" name="UTM_CONTENT" value=""> <input type="hidden"
name="UTM_TERM" value=""> <input type="hidden" name="UTM_ID" value=""> <input type="submit" class="submitbtn" value="Submit" id="checkBtn">
<div class="clr hgt20"> </div>
</form>
Text Content
HILLROM PRIVACY NOTICE AND CONSENT To receive electronic marketing communications about Hillrom’s products and services, please review the Hillrom Privacy Notice, complete the form below and give your consent by ticking the box. * = required field First Name* Please enter first name. Last Name* Please provide a last name. Email* Please provide email Hospital* Please provide hospital. Function/Specialty* Select one... IT Procurement Nurses / Clinicians Biomeds Other Professional Designation Job Role* Select one... Director of informatics Informatics Manager Informatics Analyst IT project Manager Other IT Head Buyer Director of purchasing Purchasing / Contract Manager Purchaser Other Procurement CNIO - Chief Nurse Information Officer Head Nurse Clinical Specialist (HCP) Nurse Hygienist Clinical physicist Other Clinician Chief Medical Technician Biomed Other Biomeds Other Please select Profession/Specialty City* Please provide city. Country* Choose Country... Belgium Netherlands Sweden Please select country Phone Number What would you like further information on? FLC (Welch Allyn and Mortara products) Care Solutions Yes, I confirm that I have received the Privacy Notice*. Please tick checkbox. By clicking on the Submit button, you agree to receive from Hillrom electronic marketing communications about its products, services and events, as per its Privacy Notice. ABOUT US Every day, millions of patients and caregivers rely on Baxter’s leading portfolio of critical, nutritional, renal, hospital and surgical care products and services. For more than 85 years, we’ve been operating at the critical intersection where innovations that save and sustain lives meet the healthcare providers that make it happen. Global Privacy Policy Terms of Use Cookie Policy ©Copyright 2022 Baxter. All rights reserved. COOKIE PREFERENCES By clicking “Accept All Cookies”, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. Accept All Cookies Reject All Cookies Settings PRIVACY PREFERENCE CENTER When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalized web experience. Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer. More information Allow All MANAGE CONSENT PREFERENCES STRICTLY NECESSARY COOKIES Always Active These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms. You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information. Cookies Details PERFORMANCE COOKIES Performance Cookies These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. They help us to know which pages are the most and least popular and see how visitors move around the site. All information these cookies collect is aggregated and therefore anonymous. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Cookies Details TARGETING COOKIES Targeting Cookies These cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. They do not store directly personal information, but are based on uniquely identifying your browser and internet device. If you do not allow these cookies, you will experience less targeted advertising. Cookies Details FUNCTIONAL COOKIES Functional Cookies These cookies enable the website to provide enhanced functionality and personalisation. They may be set by us or by third party providers whose services we have added to our pages. If you do not allow these cookies then some or all of these services may not function properly. Cookies Details Back Button BACK Search Icon Filter Icon Clear checkbox label label Apply Cancel Consent Leg.Interest Switch Label label Switch Label label Switch Label label * View Cookies * Name cookie name Confirm My Choices