Join Network Form

Join Network

The XETAX Network is currently in alpha stage. You can join our pre-launch phase program free of charge to benefit from our fee subsidizing & spotlighting promos for our early network joiners.

Please provide the full name of your facility (eg Put Pudarice 15I, Zadar, Croatia)

Name and address of your facility*

The field is required

Street*

The field is required

City*

The field is required

Country*

The field is required

What is your facility type*

This field is required

Email- Address*

The field is required

Email address must be a valid email”

Telephone- Number*

The field is required

Website

Total number of employees at your facility*

Number of Physicians at your facility*

Value too much, maximum - {{ $v.formData.number_of_physicians.$params.maxValue.max }}

Number of Nurses*

Value too much, maximum - {{ $v.formData.number_of_nurses.$params.maxValue.max }}

Number of Operation rooms*

Value too much, maximum - {{ $v.formData.number_of_surgical_rooms.$params.maxValue.max }}

Average procedure count per week?*

Value too much, maximum - {{ $v.formData.average_treatment_per_week.$params.maxValue.max }}

Rate of cancelation per week?*

Value too much, maximum - {{ $v.formData.rate_of_cancellation_per_week.$params.maxValue.max }}

Proof of your facility's legal registration

What are you expecting from our services?*

The field is required

Please verify captcha

Submit

*By submitting, this form, you accept our privacy policy