New Acute Hospital Client Form
Hospital Details
Legal Name
Trading Name
ABN
Group
Primary Contact Person
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Secondary Contact Person
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
After Hours Contact Number
-
Area Code
Phone Number
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your postal addressdifferent to your physical address?
Yes
No
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DON Contact Information
DON
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
ADON Contact Information
ADON
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
HNC/Roster Co-ordinator
Phone Number
-
Area Code
Phone Number
Email
example@example.com
HNC/Roster Co-ordinator After Hours
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Ward Requirements
Ward details for invoice/PO number requirements
Bed Numbers
Documentation System
Sign On Area
Parking
Please Select
Yes
No
Access information during and after hours
Invoicing
** Remittances are to be emailed through to accounts@carestaffnursing.com.au **
Invoice Contact Name
First Name
Last Name
Invoice Contact Number
-
Area Code
Phone Number
Invoice Email Address
example@example.com
Invoice Postal Address
Street Address
Street Address Line 2
City
State / Province
Post Code
Payroll Tax Exempt
Please Select
Yes
No
QLD Payroll Tax Exemption Form
NSW Payroll Tax Exemption Form
Tax Exemption Form Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Any additional information
Notes
Authorisation
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Position
Signature
Submit
Should be Empty: