Organisation Name (for the Service Agreement)(Required)Organisation Address(Required) Street Address Address Line 2 City Region Postcode Email Key Contact Name(Required) First Last Key Contact Email Address(Required) Key Contact Phone Number(Required)TBI Health representative you are dealing with:(Required)Select your representativeRobyn HumphriesPeter ButterworthKarne BealBrooke PatrickServicesWhich services would you like included? Moving and Handling Group Training/Workshop(s) for clinical staff – onsite at facility Moving and Handling Group Training/Workshop(s) for non-clinical staff – onsite at facility Physiotherapy services for aged residential care resident(s) – onsite at facility Occupational Therapy services for aged residential care resident(s) – onsite at facility Community (In-Home) Physiotherapy services for adult(s) living in private home(s) Community (In-home) Occupational Therapy services for adult(s) living in private home(s) Community (In-home) Physiotherapy services for child/children living in private home(s) Community (In-home) Occupational Therapy services for child/children living in private home(s)Select AllAre there any other services not listed that you would like included?Who shall our service provider liaise with to book in the services?(Required) Organisational Key Contact Client (or their parent/caregiver, if the client is a child) OtherPlease stateReportingBasic information (e.g. about dates, types and costs of services provided and name of facility or client service was provided to) is included on our monthly invoices. Do you require TBI Health to provide any additional reporting?(Required) Yes NoFor services where a report is required, what would you like included in the report?For services where a report is required, how frequently do you require a report? Quarterly Every 6 months Annually OtherPlease state frequencyFor services where a report is required, who would you like the report to be sent to?(Required) First Last Email address of person to receive report(Required) BillingWhich email address should invoices be sent to?(Required) Do you require a Purchase Order number or other reference on your invoices?(Required) Yes NoPlease provide purchase order number/reference:Are you happy for TBI Health to add your business logo to our website as an organisation that we work with?(Required) Yes No TBCDo you have any final comments?
