Nexus Health Collective Provider Information Form
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Website URL:
Location/s:
Service/s Provided:
Mode of service
In Clinic
Mobile
Telehealth
Serviceable regions:
NDIS Registered
Yes
No
Key interest of service: (Briefly describe the main focus, clientele, niche or specialties of your service)
Hobbies/Interests (Optional, but helpful for pairing with the right consumers. Please share any hobbies or interests related to your service or team members.)
Language/s Spoken: (Please list the languages spoken by your staff or available translators)
Fee Structure: (Provide details about your fee structure, including any payment options or financial assistance programs)
Additional information prospective consumers will find useful:
Additional information of the organisation:
At Nexus Health Collective, we are committed to protecting the privacy and confidentiality of your information. By completing this form, you consent to the collection, use, and disclosure of the information provided herein for the purpose of connecting you with prospective clients seeking healthcare services. Information Collection: We will collect personal and professional information including but not limited to your name, contact details, type of services offered, and other relevant details pertaining to your healthcare practice. Use of Information: The information collected will be used solely for the purpose of facilitating connections between you and prospective clients seeking healthcare services. It may also be used for internal record-keeping and to improve our services. Disclosure: We may share the information provided in this form with individuals or organizations seeking healthcare services through Nexus Health Collective. However, we will not disclose your information to any third parties without your explicit consent, unless required by law. Data Security: We are committed to ensuring the security of your information. We will take reasonable measures to safeguard the information collected from unauthorized access, use, or disclosure. Retention: We will retain the information provided in this form for as long as necessary to fulfil the purposes outlined in this privacy policy, unless a longer retention period is required or permitted by law. Consent: By submitting this form, you consent to the collection, use, and disclosure of your information as described in this privacy policy. Updates: We reserve the right to update or modify this privacy policy from time to time. Any changes will be effective immediately upon posting the revised privacy policy on our website
I agree
I do not agree
Signature
Continue
Continue
Should be Empty: