Anaesthetist Upgrade "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formSpecial Offer (hidden)DefaultPES UpgradeSpecial Offer AppliedPay only 50% of the Premium Price for the first three months. Month 1 = $62.50 Month 2 = $62.50 Month 3 = $62.50 Month 4 = Normal Premium $125 price applied Our plans are month-to-month with no long term commitments so you can choose to downgrade or cancel your plan at any time.New Plan*Please selectStandard Plan - $65 per monthPremium Plan - $125 per monthUpgrade from Standard to Premium - $125 per monthPES-only PackageSpecial PES Upgrade OfferYour PES payment will be applied to your upgrade. This is an invite only offer and only for a limited time. Please see our emails for when your billing will start.STANDARD PLAN * Profile Page * Contact Form * Email Address (e.g. [email protected]) * Standard Pre Op Health Questionnaire * Patient Experience Surveys (ANZCA CPD) * Notification of ListsPREMIUM PLAN * Profile Page * Contact Form * Own Domain Name (e.g. dryourname.com.au) * Email Addresses (e.g. [email protected], [email protected], [email protected] ..) * Unique Pre Op Health Questionnaire - complete customisation (e.g. unlimited changes to questions, confirmation and notifications messages) * Patient Experience Surveys (ANZCA & FPM CPD) * New Multi-source / 360-degree Feedback Forms (ANZCA & FPM CPD) * Extra FAQ Pages (e.g. patient post op info) * Notification of Lists * Premium SupportPES-Only Package (Free Plan Add On) ANZCA compliant “Patient Experience Survey” forms (adult and child) can be added to your Free profile page as a once off fee. Once you have received 15 responses we act as your Administrator to collate all of your results. We will then send a summary of all your data as a PDF Summary Report – you should then meet with a Feedback Provider (e.g a colleague / partner) to discuss your results. We will also send you a signed ‘Patient Experience Survey confidentiality and CPD verification form‘. This with a copy of your survey, that we will provide, can be uploaded to the ANZCA website to record this activity in ANZCA’s CPD program For the first order, the cost is $225, but for future renewals / Summary Reports, there is a 40% discount and the price is only $135. (If you are renewing your PES-Only package, please contact us for the renewal link)The BasicsFirst Name*Last Name*Email*Not for publication - this is where your forms, invoices and list notifications will be sent Phone*Not for publication - we will use this if we need to to contact youWould you like to change any of your existing details?eg. your about me section or photoYesNoWould you like to add on the extras available with your plan now?eg. a shortlink or (Premium) domain name, question changesYesNoChanges to your existing profileIf you would like a link or information in your About Me section to reflect your new plan (for example a link to your pre-op questionnaire) please mention it below."About Me" SectionProfile Photo (optional)Format: jpg, jpeg, png Accepted file types: jpg, jpeg, png, tif, png, gif, Max. file size: 128 MB. ExtrasIf you would like to add on any extras (included free in your new plan) please advise them below.Personal Email AddressWebsite Short LinkComplimentary Domain Name:As part of the Premium plan, you receive your own domain name (e.g. dryourname.com.au). We will continue to renew and maintain your domain name and matching email addresses at no extra charge as long as you are a paying member of Anaesthetic Group. Should you decide to leave us, you can take your domain name with you. The domain name is registered in your name.ABN numberAs we will put your name as the "Registrant" (the registered owner of the domain name) we need to list your ABN for all .com.au websites. This is so if you do decide to leave us later, you can easily take your domain name with you. You can check your ABN at: https://abr.business.gov.au/SearchMatching Email Addresses:Your domain name will be configured with a 'catchall' email account - so any email sent to an undirected @dryourname.com.au email address will be forwarded to you. (Optional) If you wish to forward specific email addresses to another email account, please enter them here. Premium Pages, Questionnaire & Form ChangesWould you like to add your 5 Extra Pages Now?(Optional) You can email us these later. We can also change them for you at anytime. Please ChooseYesNo - I will email them laterNot requiredExtra Page 1Accepted file types: pdf, Max. file size: 8 MB. Extra Page 2Accepted file types: pdf, jpg, jpeg, Max. file size: 8 MB. Extra Page 3Accepted file types: pdf, jpg, jpeg, Max. file size: 8 MB. Extra Page 4Accepted file types: pdf, jpg, jpeg, Max. file size: 8 MB. Extra Page 5Accepted file types: pdf, jpg, jpeg, Max. file size: 8 MB. Would you like to customise your questionnaire or forms now?Please ChooseYesNo - I'll email changes laterChanges to Pre-Op QuestionnairePlease be as descriptive as possible eg. Add a question "XYZ" or if they answer "ABC" to question "XYZ" then ask the patient the question "123"Changes to Feedback FormBy default, we will set up your account with the ANZCA Patient Experience Survey (for CPD). However, please advise us if you would like another feedback form.Other DetailsAny Other Feedback?Please let us know if you have any feedback or comments regarding our website, plans, or anything else.Payment InformationPlease note: Billing will begin only after your PES payment credit expires. Your PES payment will be applied to your upgrade to the Standard or Premium plan. As our Eway payment gateway can't do free periods, you will be charged $0.01 today only. Please refer to our emails for the exact date when your billing will start.PES Upgrade to Standard Plan Price: PES Upgrade to Premium Plan Price: Special - Premium 50% discountSpecial 50% discount off the Premium Plan for 3 months. Price: When you change from the Standard Plan to the Premium Plan, we can charge your credit card below and you can begin a new payment cycle from today. Your unused Standard Plan payment will then be manually refunded. Alternatively, we can pro rata your first payment by using your credit card details on file. Based on how many days are left until your next billing cycle, we will calculate and only charge the Premium value for those days, then from your next billing cycle onwards, your Premium price will apply. Please select this option if you receive referral discount(s). 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Please select a plan at the top of the page to see the correct price below. Total Credit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name CAPTCHA