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Please complete the form below. Once completed you will be presented with an invoice.

User identities.

Your user identity needs to be unique within the system.

The number of overall users should be small so we recommend using your first initial, then your surname followed by a number (perhaps the current year).

User identity:*?

Firstname(s).

Please enter your legal firstname(s). This is a compulsory field, although if you have multiple first names you need only enter the first (at your discretion).

Firstname(s):*?

Preferred name.

If you prefer to be address other than your firstname(s) please enter your preference here.

Prefered name:?

Surname.

Please enter your surname. This is a compulsory field

Surname:*?

Email.

Email is our main method of communication and therefore a requirement.

Email:*?

Phone No.

This is only for when email fails and we still need to contact you, and you would like us to be able to.

Contact phone No.:?

Recertification programme

We have various questionnaires and reports designed for different recertification programmes. You should select the one most appropriate for you.

Failure to select will leave you with our default form options.

Recertification programme:?

Requirements

Select the 'feedbacks' you want to do.

Your requirements:*?
This is the default collegial feedback.
Through this web-app you will supply at least 10 names and emails for colleagues, who will then receive an email with a link to a survey. Once at least 10 replies are received you can close off the process and view your aggregated report. Full guidance is provided in the app.
? View form
This is the default patient feedback.
Through this web-app you will supply at least 30 (probably many more) email addresses for patients, who will then receive an email with a link to a survey. Once at least 30 replies are received you can close off the process and view your aggregated report.
Full guidance is provided in the app.
? View form
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