CUSTOMER REQUEST FORM

CUSTOMER SERVICES REQUEST FORM

Please fill out the form below to submit your request. Select the type of request to help us direct your issue to the appropriate team. We aim to respond to all new or change requests within 24-48 hours and will prioritise bugs accordingly to our policies.
Section 1: Contact Information
Company/Business Name as Data Controller*
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Section 2: Healthwoosh Services Request
Request for a New ServiceResource Request Support (design, app editor publish etc)Integration Request/Upgrade RequestBug/IssueApp Store PublicationOther

Section 3: Bugs/Issues

Please capture sufficient detail to report a bug so that issue can be reproduced and/or investigated.
Product/Area Affected*
Please Indicate Handset Model
Issue Title*
Description of issue*
Steps to Reproduct*
Itemise steps in sequence
Enter Handset Make and Model (e.g. Iphone 13)*
Expected result vs Actual Result*
Critical - Service DownHigh - FrequentMedium - not affecting service but not idealLow - add to future drop for fix/update
Attach Screenshots, other details here to support request*

Cancelof

Section 4: Resource Support

If you need support for design, enhancements or other to support operations, send requests here and we can allocate additional supports on request. We have some instant models or can propose back a model to match your business support needs.
Resource Support Request Type*
All additional support requests require Healthwoosh to allocate your request to our wider network of resources and partners or training material to your staff. Additional resource requests or needs required additional support packages as will be proposed in response to cater for your needs.
Support Requirement Description*
Yes am Aware - ProceedAdvise/Quote Me First

Section 5: Integration Request or Service Upgrade Request

Many enhancements you have full control over via our interfaces, and controls per relevant platforms or services or via your own processors or sub processors. Please ensure to read our Terms, Policies and Default DPA unless you have separate agreements. It is your responsibility to manage your service and we can support with options below but at all times you need to manage the specification and integration options but you must consider end to end service and workflows and all data responsibilities in any service integration request and workflow design.
Request Title*
Request Type*
Current Version/Setup Description*
Request Details and Specification*
Support Documentation for Request*

Cancelof
Aspirational Date Required*

MonthDayYear
Dates not gaurenteed, this is for priority planning at Healthwoosh only.
Additional Notes*

Section 6: Data Concern

Please initially read our default terms/conditions, privacy policy and DPA.
Default Terms & Conditions at https://healthwoosh.com/termsDefault Privacy Policy at https://healthwoosh.com/privacyDefault Data Protection Agreement at https://healthwoosh.com/dataprotectionpolicySeparately Agreed Contract Terms Directly with HealthwooshNo Contract or Service, an Enquiry Only
Request Title*
Description*
Healthwoosh is only obligated to reply to Data Controllers

Section 4: Terms, Conditions and Default DPA

Please agree to our default terms and conditions. You may request a different commercial, contract relationship and if so please contact us directly. To use any of our services you are by Default agreed to all our default terms, policies and DPA. Please read and confirm by either click below or initiating payment to our invoices that reference these terms as available on our website.
Agree to Default Terms & Conditions at https://healthwoosh.com/termsDefault Terms & Conditions at https://healthwoosh.com/termsHave Read Default Privacy Policy at https://healthwoosh.com/privacyAgreed to Default Data Protection Agreement at https://healthwoosh.com/dataprotectionpolicy
Please verify that you are human*
Should be Empty:

CUSTOMER SERVICES REQUEST FORM