Consultation Preferences

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

* Do you wish to consult with other health practitioners but not directly with clients/patients?
YesNo
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

Title:     

First Name:             

Surname:                

Post-nominals:           

* Profession:              

Position Title:             

* Workplace Name:    

Street Address:          

* Suburb/Town:         

* State/Territory:              * Postcode:  

Landline Phone:                  Fax:  

Website:                     

* 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?    

Qualifications:

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):
Face-to-FacePhoneTelemedicineSkypeFaceTimeOther

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.