Order

Patient feedback for hearing clinics order form

Insync will provide you with the tools to facilitate your surveys online. At an additional cost of $50, we can also provide you with a PDF copy of the survey for you to print; in this case, you can use both methods to maximise patient participation.

Benefits of doing your surveys online:

a quicker report turnover time (no more than 48 hours)
get your results live on the interactive portal
beneficial for the environment

You’ll also receive

poster template, QR code poster, patient information form, clinic checklist
survey drop box and reply paid envelope to return completed paper surveys (if paper forms have been selected)
management of the data entry and analysis process
dashboard summary report with identified areas for improvement and recommended actions
online interactive report for self-analysis

1. Survey administration method

Please note that the selection of ‘online and paper’ incurs an additional cost of $50.

How will you administer the surveys?*

Online only

Online and paper (online survey via URL and QR code, and paper)

2. Annual subscription selection

The survey will run for a 3 month period, an annual subscription is available should you want to run a continuous survey. Annual subscriptions are charged at $50 which includes a quarterly scorecard report.

Would you like an annual subscription?

Annual subscription?*

Yes

3. Calculate the number of FTE clinicians in your clinic

To calculate your number of FTEs, divide the total number of clinician hours worked per week by 37 and round up to the nearest whole number.

You can use our quick calculator on the right side of this page to determine your clinic’s FTE number.

Select the number of FTE clinicians below. For 21+ FTE pricing please contact us.

Number of FTE's*

Subtotal

$ 0.00

GST

$ 0.00

Total Due (inc GST):

4. Fill in your clinic details

Clinic Name*

Clinic Address*

Suburb*

State*

Postcode*

Primary Contact First Name*

Primary Contact Last Name*

Phone Clinic*

Phone Mobile

Email Address*

How did you hear about us?

Other

5. Payment Method

Payment Method*

Credit Card (VISA or Mastercard)

EFT

Bank details for EFT:
Account Name: Insync Surveys Pty Ltd
ABN: 58 108 768 598
BSB: 083 170 Account No: 439657084

Credit Card*

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Acknowledgement*

I acknowledge that our surveys will be printed in accordance with Insync printing instructions (to be sent with survey materials) to avoid delayed turnaround times.

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Order ID

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