Practice Registration form

Please enter the name of the Practice you are registering

Practice Name

Address of the Practice

Street Address

Street Address Line 2

City

Region

Postcode

Country

Practice Phone Number

Area Code

Phone Number

Name of primary contact person

First Name

Last Name

Email address for primary contact person

example@example.com

Confirm Email

Business DetailsWhat is the name of the business that owns the Practice

Business name

Trading name

Business type

NZ Business Number (NZBN)

What email address should we send invoices to?

Who do we contact for invoicing/payment questions?

Invoicing for our ServicesWe invoice our customers at the end of each week and our invoices have 7 day payment terms so that we can pay our locums promptly.

Where should we email invoices to?

Who do we contact for invoicing/payment questions?

Practice Details* This field is required.

Practice type

Approximate enrolled patient count

Patient Management System

How quickly do you need a locum?

What services does your practice need?* This field is required.You can select as many options as you need.

GP Sessional cover

GP Inbox cover

GP Triage

Repeat prescription processing

In-practice video consultations

Would you be interested in locums covering sessions outside of standard business hours (e.g. Saturday morning clinics, or late night clinics during the week)

YESNO

What days would you expect Remedi contractors to be available?Remedi contractors are available 0800-2200 Monday to Friday, other days by arrangement

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Public Holidays

How did you hear about Remedi?

Referral from a friend

Internet Search

I know Gordon and / or Richelle :-)

Facebook

Practice Registration form