Embark Potential Pty Ltd collects the information you provide in this form—including your name, practice, work contact details and any optional note—to process your request, create a practice-specific referral link and QR code, coordinate the design, printing and delivery of practice-specific brochures, contact you about the request and maintain relevant administrative records.
When you submit the form, limited technical and security information, such as your IP address, browser or device information and submission time, may also be recorded.
Providing this information is voluntary. Your phone number and note are optional. Without the other required information, we may be unable to process your request.
Information provided through this form is transferred directly to and stored in Embark Potential’s Replit production environment, configured for Replit’s Australia publishing geography. It is not routed through ordinary email. Replit is a United States-based provider and may use overseas personnel or subprocessors for infrastructure, security, operational or support functions, as explained in our Privacy Policy.
This form is not intended for patient or clinical information. Do not include any patient-identifying, health or clinical information.
Our Privacy Policy explains how we protect personal information and how you may request access or correction or make a privacy complaint. For privacy enquiries, email Admin@embarkpotential.com.au.