Trauma Centre Australia

CRITICAL INCIDENT & TRAUMA RESPONSE

If a traumatic incident occurs in your workplace, we will be there to help you and your organistion deal with it.

Trauma Authority Form

Date of incident:*
Job No:

COMPANY CONTACT PERSON:

Contact Name:*
Position Title:*
Telephone:*Please include your area code
Mobile:
Fax:

COMPANY & BILLING DETAILS:

Company Name:*
ABN:*
Branch/Department:*
Address:*
Suburb/City:*
Postcode:*

TERMS AND CONDITIONS:

Fee Per Hour (or part thereof): [ $ ] For initial and subsequent service and travel. All trauma response services and travel are charged at the appropriate hourly rate to the nearest 15 minute interval. Travel is charged to and from location of consultation and the location of primary TCA offices (throughout Australia).

Payment terms: Strictly 14 days from receipt of tax invoice. Failure to make payment (or payment arrangements with our office) within a reasonable time period may result in legal action being pursued and additional costs being incurred.

Please complete and sign section below to accept the terms and conditions as indicated above and fax to the Trauma Co-ordinator on 03 9855 2524, within 24 hours of initial date of service.

AUTHORITY:

I, , of , declare that I have read and accept the terms and conditions contained in this document.

 

SIGNED: DATE:

 

PRINTED NAME: TITLE: