Your Contact Details And Qualifications

Title:  —Please choose an option—ProfessorAssociate ProfessorDoctorMrMrsMsMissOther   

First Name:             

Surname:                

Post-nominals:           

* Profession:              —Please choose an option—AcupuncturistAnaesthetistCase ManagerChiropractorDietitianExercise PhysiologistGeneral PhysicianGeneral PractitionerMassage TherapistMultidisciplinaryNaturopathNeurologistNeurophysiotherapistNurseNutritionistOccupational TherapistOrthopaedic SurgeonOrthopaedistOrthotistOsteopathPedorthistPhysiotherapistPodiatristPsychiatristPsychologistRehabilitation PhysicianRemedial TherapistRespiratory PhysicianSocial WorkerSpeech PathologistOther

Position Title:             

* Workplace Name:    

Street Address:          

* Suburb/Town:         

* State/Territory:       —Please choose an option—ACTNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia       * Postcode:  

Landline Phone:                  Fax:  

Website:                     

* Mobile:                    
* Are you willing to have your mobile number published in the Register?   —Please choose an option—YesNo

* Email:                     
* Are you willing to have your email address published in the Register?    —Please choose an option—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.

Thank you for completing this form. Send your details through to Polio Australia by clicking the "Submit your details" button below.

Once the form has been successfully submitted, a copy of the details that you entered will also be emailed to you for your records.

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