Medical Centre Questionnaire & Business Nominations

Tell us a bit about your practice

Complete the form below to confirm your request for our services. Please ensure you review the terms and conditions at the bottom of this form.

Questions?

Talk to our team for more information, we are ready to help you!

Reach us:

+61 7 5699 8109
info@medicaltogether.com.au
PO Box 343, West Burleigh, QLD 4219

1Your practice information
2Your business nominations
Complete the form below to supply us with a list of your preferred medical centre sponsors. You do not need to complete every field, just your preferred business nominations. If you have any businesses or categories you would like to exclude, please list them in the comments field at the end of the form.
Pharmacy
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Physiotherapist
Business Name
Contact Name
Phone
Business Name
Phone
Contact Name
Business Name
Contact Name
Phone
Podiatrist
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Optometrist
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Dentist
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Counselling / Psychology / Psychiatry
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Radiographer
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Pathology Collection
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Audiologist
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Business Name
Contact Name
Phone
Services that patients usually access frequently:
Occupational Therapist
Business Name
Contact Name
Phone
Speech Pathologist / Therapist
Business Name
Contact Name
Phone
Private Hospital
Business Name
Contact Name
Phone
Aged Care Facility / Services
Business Name
Contact Name
Phone
Mobility Aids
Business Name
Contact Name
Phone
Dietician / Nutritionist
Business Name
Contact Name
Phone
Additional health related services of benefit
Fitness Centre / Personal Trainer
Business Name
Contact Name
Phone
Massage Therapist
Business Name
Contact Name
Phone
Osteopath / Chiropractor
Business Name
Contact Name
Phone
Orthodontist / Denture Clinic
Business Name
Contact Name
Phone
First Aid Training
Business Name
Contact Name
Phone
Pilates Studio / Yoga
Business Name
Contact Name
Phone
Family related services of benefit
Childcare Centre
Business Name
Contact Name
Phone
School / College
Business Name
Contact Name
Phone
Relaxation & Wellbeing services of benefit
Day Spa / Skin Care / Beauty Salon
Business Name
Contact Name
Phone
Hair Studio
Business Name
Contact Name
Phone
Additional Local services
Accountant / Book Keeper / Financial Planner
Business Name
Contact Name
Phone
Lawyer / Solicitor
Business Name
Contact Name
Phone
Travel Agent
Business Name
Contact Name
Phone
Florist
Business Name
Contact Name
Phone
Real Estate
Business Name
Contact Name
Phone
Cafe
Business Name
Contact Name
Phone
Funeral Services
Business Name
Contact Name
Phone
Holistic Therapies
Business Name
Contact Name
Phone
Thank you!

We appreciate you taking the time to supply us with your preferred sponsors. If you have any additional comments or business categories or businesses you would like to exclude, please list them in the section below.
Notes
Consent*
I have permission to act on behalf of the medical centre and agree to the terms listed below.*
Agreement between Medical Together (“The Company”) and “The Client”, providing services for “The Centre”

1. Appointment Cards

1.1 The Company agrees to supply the advertisement backed information/appointment cards to The Client, totally free of charge.

1.2 This agreement shall commence on the date hereof and The Centre hereby agrees to distribute the cards to their patients for a minimum of two years once the publication is printed.

1.3 The Company reserves the right not to proceed to print until sufficient sponsorship is gained.

1.4 The Centre agrees not to use an alternative sponsored appointment card.

1.5 This agreement may only be terminated by either party subject to written notice effective 24 months after the current sponsorship term.

1.6 If the Centre changes ownership or control the client must inform the Company of the change and provide the Company with the date of the change in ownership or control and must do all things necessary to facilitate the novation of this Agreement to the proposed transferee or controlling entity.

2. Website

2.1 The Company agrees to provide The Centre with a professional website with up to date information regarding the medical centre’s services, staff and contact details. The site will include click-to-call buttons, booking integration and contact forms if requested.

The website provided will be mobile and tablet responsive and optimised for search engines.

The Company will utilise an SSL certificate to ensure the website is secure and has a better chance of ranking in Google.

2.2 The Centre must utilise the website provided as their primary website and refer to only this website when referencing their website and will do so for a minimum duration of 2 years from live date.

2.3 The website will contain banners promoting local businesses who have chosen to sponsor The Centre.

2.4 The Company will work to ensure that the website that is developed represents the brand and identity of the medical centre.

2.5 Whereby The Company is unable to obtain sponsorship of the website The Client agrees to pay a one off fee of $600.00+gst to cover development costs plus ongoing website hosting costs of $220.00+gst per year.

3. Website Updates

3.1 The Company will provide The Client with access to the CMS allowing them to make updates to the content of the website. The Client must not remove the sponsored features from the website. The Company will provide updates to the website upon request. In the case where these updates or additional features incur a fee, The Centre will be advised in advance.

4. Website Ownership

4.1 Ownership of the website and its assets remain that of The Company. The Centre domain name remains the property of The Client. Should The Client decide to end the sponsorship arrangement after the 2 year cycle, an option for The Client to purchase the website is available for a fee of $2,000.00+gst.

5. Privacy

5.1 The Company will not share specific private information regarding the website with 3rd parties with the exception of reporting total traffic through the website with sponsors and reporting the click rates on their sponsored features.

6. Termination

6.1 This agreement runs for a minimum period of 24 months from the commencement of sponsorship and cannot be terminated prior to the expiration of sponsorship without compensation.

7. Change of Ownership

7.1 If the Centre changes ownership or control the client must inform the Company of the change and provide the Company with the date of the change in ownership or control and must do all things necessary to facilitate the novation of this Agreement to the proposed transferee or controlling entity.

8. Acting on Behalf of The Centre

8.1 In order to facilitate the sponsorship process The Client grants permission to The Company to act on behalf of The Centre throughout the duration of this agreement.

9. Conflicts

9.1 Prior to sourcing sponsorship, the Company carries out stringent processes to avoid any conflict of interest with inhouse services/allied health providers. In the event of additional services/allied health providers joining the practice after sponsorship has been finalised, whilst every effort will be made to reposition the sponsor, the Company reserves the right to retain the sponsors on the cards/website for the full term of the sponsorship cycle.

Save and Continue Later

Tell us a bit about your practice

Questions?

Reach us:

Pharmacy

Physiotherapist

Podiatrist

Optometrist

Dentist

Counselling / Psychology / Psychiatry

Radiographer

Pathology Collection

Audiologist

Services that patients usually access frequently:

Occupational Therapist

Speech Pathologist / Therapist

Private Hospital

Aged Care Facility / Services

Mobility Aids

Dietician / Nutritionist

Additional health related services of benefit

Fitness Centre / Personal Trainer

Massage Therapist

Osteopath / Chiropractor

Orthodontist / Denture Clinic

First Aid Training

Pilates Studio / Yoga

Family related services of benefit

Childcare Centre

School / College

Relaxation & Wellbeing services of benefit

Day Spa / Skin Care / Beauty Salon

Hair Studio

Additional Local services

Accountant / Book Keeper / Financial Planner

Lawyer / Solicitor

Travel Agent

Florist

Real Estate

Cafe

Funeral Services

Holistic Therapies

Thank you!