New MedcallClientAccountForm

Facility
Facility Name:
Legal Name:
Number of Beds or Patients:
Any Special Requirements:
eg certifications
Facility Main Phone:
Facility Mobile Phone:
Address
Physcial Location:

Source address:

Found address:

Address search:(search, then select)
Physical Address:
Where we will send staff
Region:
Billing Address:
Copy from above
Client Contact
This should be the person who will sign the contract with Medcall (via online signature).
Signatory Name:
Signatory Designation:
We will send an email with a copy of the signed contract.
Signatory Email:
Online User Management:

Create a user account in Medcall client portal
Manager / Nurse Manager
Please tell us the name and contact details of the person who will be managing Medcall staff.
Manager Contact:

Same as signatory Different person
Manager Name:
Manager Mobile Phone:
Manager Email:
Online Bookings:

Create a user account in Medcall client portal
Accounts
Accounts Contact:

Same as signatory Same as manager Different person
Accounts Contact Name:
Accounts Phone:
Billing Email:
Online Invoice Viewing:

Create a user account in Medcall client portal