YIHA Sign Up

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Your Name

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Confirm Email

Please provide your preferred contact email here

Phone Number

Please provide your preferred contact number here

Practice Website

Please provide your website address. we need this to theme your forms (ie. www.medicalpractice.com)

Practice / Company Name

The name of your overarching organisation which may own one or more branches / practices.

List of Branches and Managers

Surgery 1 – Ms J.Smith , Practice 2 – Mr A.Person, Clinic 3 – Ms A.Manager etc

List of Clinicians (and role) at each branch

Dr J.Smith – GP at Clinic 3 Dr A.Person – ANP at Practice 2 etc

Email(s) for form

You can have a single email or multiple here. If you’d like emails from each branch to go to different sources (on or more emails), please let us know here (branch 1: [email protected] & [email protected], branch2: [email protected] or all branches [email protected] etc)

Adjutant Health