Practice Advisory Services - Booking Form
Practice details
Contact person
*
First Name
Last Name
Job title
*
Practice Owner
*
First Name
Last Name
ADAQ member number
Practice Owner 2 (if applicable)
First Name
Last Name
ADAQ member number
Practice Name
*
Practice Advantage ID (if applicable)
Type of practice
*
(i.e general, specialist - please specify)
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Practice website
Number of practice staff
*
Number of surgeries/rooms
*
Is your billing address the same as your practice address?
*
Yes
No
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What services would you like to book?
*
Practice Health Check up
Infection Control / Radiation Safety Staff Training
Infection Control Services (incl. Staff Training)
Accreditation Document Development
Re-accreditation Document Review & Submission
General Consultancy
Practice Health Check up
Who will be your nominated representative at this visit?
*
First Name
Last Name
How many hours would you like to book the consultancy?
*
1 hour
2 hours
3 hours
3+ hours
What challenges/issues are you facing in your practice?
*
In order of priority, what issues would you like to discuss during your consultation?
*
Are there other reason/s you are seeking ADAQ support?
Infection Control / Radiation Safety Staff Training
Who will be your nominated representative at this visit?
*
First Name
Last Name
What Infection Control challenges/issues are you facing in your practice?
*
Are there other reason/s you are seeking ADAQ support?
Are there any other issues that you would like to discuss during the visit?
How many hours would you like to book the training session?
*
1 hour
2 hours
3 hours
3+ hours
In order of priority, what issues would you like to include in your staff training session?
*
Infection Control Services (incl. Staff Training)
Who will be your nominated representative at this visit?
*
First Name
Last Name
What Infection Control challenges/issues are you facing in your practice?
*
How many hours would you like to book the training session?
*
1 hour
2 hours
3 hours
3+ hours
In order of priority, what issues would you like to include in your staff training session?
*
Are there other reason/s you are seeking ADAQ support?
Are there any other issues that you would like to discuss during the visit?
Accreditation and Re-accreditation Document Development
Who will be your nominated representative at this visit?
*
First Name
Last Name
Are you currently registered for accreditation?
*
Yes
No
When is your allocated completion time?
*
-
Day
-
Month
Year
Date
Are you interested in one of these services:
*
ADAQ working with you to customise and submit your application
A face-to-face visit at ADAQ to discuss the process and requirement
Phone or email assistance.
Are there other reason/s you are seeking ADAQ support?
Are there any other issues that you would like to discuss?
General Consultancy
Who will be your nominated representative at this visit?
*
First Name
Last Name
How many hours would you like to book the consultancy?
*
1 hour
2 hours
3 hours
3+ hours
What challenges/issues are you facing in your practice?
*
In order of priority, what issues would you like to discuss during your consultation?
*
Are there other reason/s you are seeking ADAQ support?
Submit
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