Consultation Preferences

* Do you wish to consult with clients/patients?
If yes, please continue answering all relevant questions

* Do you wish to consult both with polio survivors and with other health practitioners to assist them with their own clients or patients?
If yes, please continue answering all relevant questions

* Do you wish to consult with other health practitioners but not directly with clients/patients?
If yes, please:
1) provide relevant contact details;
2) under ‘Type of Practice’, select ‘Consultant to Health Practitioners’; and
3) complete the Qualifications, Professional Affiliations, Brief Bio and Late Effects of Polio Experience/Training/Interests questions.
Other questions can be left blank.

Your Contact Details, Qualifications and Brief Bio


First Name:             



* Profession:              

Position Title:             

* Workplace Name:    

Street Address:          

* Suburb/Town:         

* State/Territory:              * Postcode:  

Landline Phone:                  Fax:  


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

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


Professional Affiliations:

Brief Bio (max 200 words):

Your Practice Details

* Type of Practice:    

Doctor's Referral Required:  YesNo

Days of Operation:  MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Operating Hours:    

* Is your workplace wheelchair accessible?  YesNoNot Applicable

Consultation Options (select all that apply):

Do you do home visits?  YesNo

Do you provide an after hours service?  YesNo

Any additional information about your services/location/parking etc:

Fees (select all that apply):
Private BillingPrivate Health InsuranceMedicare Bulk BillingHealth Care CardPension CardDVA CardNDISWorkcoverOther

Your Experience, Training and Clinical Interests:

* Late Effects of Polio Experience/Training (use Ctrl-click to select all that apply):

Specific and/or Other Areas of Interest/Expertise (use Ctrl-click to select all that apply):

For Our Records:

* How did you hear about Polio Australia’s Health Professionals Register? (use Ctrl-click to select all that apply):

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 in the white box below to confirm you are a human (a green tick will appear), then click the "submit your details" button beneath.

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