Your Contact Details And Qualifications

Title:  ---ProfessorAssociate ProfessorDoctorMrMrsMsMissOther   

First Name:             

Surname:                

Post-nominals:           

* Profession:              ---AcupuncturistAnaesthetistCase ManagerChiropractorDietitianExercise PhysiologistGeneral PhysicianGeneral PractitionerMassage TherapistMultidisciplinaryNaturopathNeurologistNeurophysiotherapistNurseNutritionistOccupational TherapistOrthopaedic SurgeonOrthopaedistOrthotistOsteopathPedorthistPhysiotherapistPodiatristPsychiatristPsychologistRehabilitation PhysicianRemedial TherapistRespiratory PhysicianSocial WorkerSpeech PathologistOther

Position Title:             

* Workplace Name:    

Street Address:          

* Suburb/Town:         

* State/Territory:       ---ACTNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia       * Postcode:  

Landline Phone:                  Fax:  

Website:                     

* Mobile:                    
* Are you willing to have your mobile number published in the Register?   ---YesNo

* Email:                     
* Are you willing to have your email address published in the Register?    ---YesNo

Qualifications:

For Our Records:

* How did you hear about Polio Australia’s Health Professionals Register? (use Ctrl-click to select all that apply):
Post-polio client/patientPost-Polio Clinical Practice WorkshopPolio Health and Wellness RetreatPost-Polio ConferenceColleagueFamily/FriendPolio Australia publicityPolio Australia WebsitePolio Health WebsiteMedia - please give details belowOther - please give details below

Comments / Feedback:
If desired, please use this space to provide comments or feedback on the Health Professionals Register and/or the Register Form.

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