AMS QUESTIONNAIRE

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* AMS Key Contact Details (these details will NOT be included in your promo )

Your Name

Email Address

Phone Number (include area code)

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* AMS DETAILS (this information may be included in your promo)

AMS Name

Address

Suburb / Town / Community

State

Postal Code

Email Address

Phone Number (include area code)

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* Description of your AMS

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* Opening hours (Mon- Fri and Weekends)

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* Clinical Hours (Mon- Fri and Weekends)

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* House Call Doctor Phone Number

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* Mobile Clinic Contact Details

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* Your AMS Health Services (please list key health services)

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* Specialist Health Services

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* Website Address

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* Social media addresses eg Facebook, Instagram

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* Any other information or comments

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* Please check this box to agree to the following terms

The Aboriginal Medical Service (AMS) confirms that they have the publishing rights to all visual assets provided to Tonic Health Media and Aboriginal Health Television (AHTV) and grant the rights and license to use the images or designs provided for the purpose of promoting your Aboriginal Medical Service (AMS) across the Tonic Health Media network. The AMS represents that they are the author and or the owner of all rights to the Artwork and herein grant that Tonic Health Media (THM) and Aboriginal Health Television (AHTV) will not infringe on the rights of any third party with the use of the Artwork.