DRAFT v0.1 — 11 November 2026 — Draft for discussion. Not legal advice. To be reviewed by Nigerian legal counsel before signature or publication.
This Order Form is made under and incorporates the Master Services Agreement, the Data Processing Agreement (Schedule 2) and the Retention & Exit Policy (Schedule 3) between {{COMPANY_LEGAL_NAME}} and the Hospital below. By signing, both Parties agree to those documents.
| Hospital legal name | ______________________________________________ |
| Hospital address | ______________________________________________ |
| Hospital contact (name / role) | ______________________________________________ |
| Hospital contact email / phone | ______________________________________________ |
| Chosen subdomain | ______________________.velnovahealth.com |
| Number of sites | __________ (all sites operate within the single tenancy above unless a separate Order Form states otherwise) |
| Start date | ______ / ____________ / 20______ (DD Month YYYY) |
| Module | Subscribed? | Tier / notes |
|---|---|---|
| Imaging module (cloud DICOM storage, worklist, viewer, reporting, e-signature, verification) | ☐ Yes ☐ No | Tier: ______________ |
| EMR module | ☐ Yes ☐ No | Tier: ______________ |
| Dictation (Deepgram) add-on | ☐ Yes ☐ No | Included minutes/month: __________ |
| Included study volume | __________ studies/month | Overage: ₦__________ per study |
| Included storage | __________ | Overage per Order Form rates |
| Users | Unlimited staff accounts within the tenancy | — |
| Subscription fee | ₦ __________________ per ☐ month ☐ year |
| One-time onboarding / training fee (if any) | ₦ __________________ |
| Billing cycle | ☐ Monthly in advance ☐ Annual in advance |
| Payment method | ☐ Bank transfer ☐ Card (payment provider) — details on invoice |
Fees are exclusive of VAT where applicable. Fee changes follow clause 3.4 of the Master Services Agreement. Termination and exit follow clause 10 of the Master Services Agreement and the Retention & Exit Policy, including the 90-day notice period.
For the Hospital
Name: ______________________________ Title: ______________________________
Signature: ______________________________ Date: ______ / ____________ / 20______
For {{COMPANY_LEGAL_NAME}}
Name: ______________________________ Title: ______________________________
Signature: ______________________________ Date: ______ / ____________ / 20______
Provider contact for this Order Form: {{CONTACT_EMAIL}} · {{COMPANY_ADDRESS}}
Draft v0.1 · 11 November 2026 · One page when completed. Attach or reference the Master Services Agreement, Data Processing Agreement and Retention & Exit Policy as provided to the Hospital.