IDS UK
Healthcare Services

Practice name:
Address:
Town:
County:
Postcode
Telephone number:
Fax number:

Contact name:
Position:
Email address:
Tel. no.:

In the boxes provided please enter the number of the following in your surgery:

Doctors:

Nurses:

Nurse prescribers:

What clinics are currently run in your surgery and what quantities of patients subscribe to these?

Allergy:		Diabetes:		Travel clinic:
Anti-smoking:		Nutition & diet:		Vaccination:
Asthma:		Heart helath:		Well man:
Baby clinic:		STD:		Well woman:

How many registered patients do you have? Is there a particular demographic lending (Age)?

18-29

30-39

40-49

50-59

60+

What are your surgery hours?

Open AM:		Close AM:
Open PM:		Close PM:

Half days / Regular closures: (please state days and times)

What parking facilities would be available to out field staff?

Surgery car park:		Off road parking:		Metered Parking:
Roadside spaces:		No parking:

In the space below please detail availability of spaces and distance to the surgery:

Where would you like the rack to be installed?

• Please note that the rack cannot be installed in treatment rooms.
• Please check that appropriate wall space is available (H107 × W67 × D11cms )

Waiting room:

Reception:

Foyer:

When visiting your surgery would our staff be entering a dangerous area where they may have to take precautionary measures?

yes:

no:

Please provide any further information that may be relevant in the space provided:

Please read the service agreement in the text area below carefully, by ticking the box you are agreeing to make payment of £200 to Waiting Room Information Services should the free standing rack be lost, or disposed of without prior permission. By asking you to cover the manufacturing costs of missing racks it ensures that we are able to continue operating this service on a free of charge basis. Please be assured that we will not be asking for any kind of payment for any normal wear and tear, rack maintenance, or leaflet supply. Once you have been accepted to receive the service, the leaflet display rack will be delivered to your surgery. Following this delivery a key installer will visit your surgery to assemble the rack and determine effective and safe positioning. On signing the enclosed agreement you will also agree not to move the rack from this position without prior authorisation from our office; and that Waiting Room Information Services cannot be held responsible for any damage/injury caused by the misuse of the rack.

£200.00 will be payable by the above site on loss or disposal of the free standing leaflet display rack, unless former authorisation has been given by the Waiting Room Information Services Head office. The free standing rack will not be moved from the agreed position, unless former authorisation has been given by Waiting Room Information Services head office. Waiting Room Information Services cannot be held responsible for any damage/injury caused by misuse of the free standing leaflet display rack.

Please tick this box to indicate you have understood the service agreement.