Initial Setup Form

Please complete this form to provide your own details and your Practice details to SurgeryWeb – on submission of this form you will be taken to the SurgeryWeb Agreement which details the cost and minimum term, and this must be signed and submitted before your new website will be set up.

"*" indicates required fields

Which SurgeryWeb template would you like to sign up for?*

Not sure? Take a look at the options here

Your Name*

Your Role*

Your Email*

Practice Name*

Practice Organisation (ODS) Code*

Name of your ICB*

Practice Address*

Street Address Address Line 2 City ZIP / Postal Code

Practice Telephone Number*

Do you have an existing website?*

Yes

Web Address (URL)*

Who is your current supplier?*

This is required to request that your domain name be transferred to us.

What email address would you like the online forms to send submissions to?

How did you hear about SurgeryWeb?*

Google

PracticeIndex

Purchase Direct

Recommendation from another Practice

Other

What is your registered username?*

Promo Code*

Please enter their NACS/ODS Code here*

If you have been referred, you and your referring Practice will both receive 5% discount off your first (or next in their case) invoice.

By using this form you agree with the storage and handling of your data by this website. *

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Initial Setup Form

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