By simply filing out the form below you can connect a patient's television. Once received a HTR representative will confirm with you the correct pricing and details and the television and or phone will be activated. Alternatively you can call our 1800 063 829 and talk with one of our friendly staff help desk staff .

If you are on site you can fill out a form and place money and patient information into a locked box which is located in every ward.


Name*:
Contact Number*:
Contact Email Address*:
Patient's Name*:
Hospital*:
Ward*:
(if unsure write "See comments below")
Bed*:
(if unsure write "See comments below")
Length of Stay:
(if known)
Comments:
(if any exact details above are unknown, please specify here)


 



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