2024 Intake Form
The information you provide will help us to provide the most relevant information and products to you.
About You
About Your Practice
Your Practice Software
Best Practice
Medical Director
Power Diary
Other
Sales and Payment Systems
TYRO
Hi-Caps
Cash or EFTPOS only
Other
What is your Billing Policy?
Please Select
100% Bulk Billed
100% Privately Billed
Mixed Billing
How many Health Providers in your practice?
GP - VR
GP - Non-VR
Allied Health
Specialist
Other
Qty
Tell us about your patients
Total:
% Concession Card Holders
Total Active Patients
Over 75
Chronic Condition
Mental Health Condition
Nursing Home
Aboriginal or Torres Strait Islander
Chronic Pain
Disability
When is the best time for our team to give you a call?
Anytime
Business Hours only
After Hours Only
Other
Who should we contact?
Please Select
Myself
My Practice Manager named above
Someone else
Name of Alternate contact:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Submit
Should be Empty: