Bone and Joint Decade 2000

questionnaire

Arthritis Health Services Guide - Questionnaire and Authorisation Form

Abbott has partnered with The Bone and Joint Decade 2000 – 2010 to develop an
Arthritis Health Service Guide.

The purpose of this guide is to provide people living with arthritis an up to date resource for seeking arthritis health services in Australia.

Your organisation has been identified as a resource specialising in arthritis care, products and services.

Please complete the following form if your organisation would like to participate in this guide. By completing this form, you authorise Abbott and The Bone and Joint Decade 2000 – 2010 to use these details in the Arthritis Health Service Guide.

For more information on the Arthritis Health Service Guide, please contact:

Ben Horgan
Chairman, The Bone and Joint Decade 2000 - 2010
Ph: 08 9388 4407
convenor@bjd.org.au

Thank you very much for your consideration and participation.

Organisation/Resource Name:
In 100 words or less, clearly describe the services a patient could expect to receive from a member of your organisation.
Words remaining:

Please indicate below the best way for a patient to access the information they need to find a practitioner who is a member of your organisation.
Main Contact Details		Alternate Contact Details
Address:		Address:
Phone:		Phone:
Website:		Website:
Email:		Email:
If you have additional contact details, such as different details for other states, please provide them in the space below

For verification purposes, if required, please provide the following information.
Your Name:
Your Position / Title:
Your Contact Details:

If your form does not submit, please remove some of the data from the "Additional Contact Details" area. Alternatively, submit a seperate entry for each state branch of your organisation.