Sign Up 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: ---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: Professional Affiliations: Brief Bio (max 200 words): Your Practice Details * Type of Practice: ---General PracticePrivate ConsultantPrivate ClinicPrivate HospitalPublic HospitalCommunity Health ServiceConsultant to Health PractitionersOther 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): Worked with post-polio clients/patientsParticipated in a Post-Polio Clinical Practice WorkshopParticipated in a Polio Health and Wellness RetreatAttended a Post-Polio ConferenceRead extensively on the Late Effects of Polio/Post-Polio SyndromeOther Specific and/or Other Areas of Interest/Expertise (use Ctrl-click to select all that apply): Neurological ConditionsNeuromuscular ConditionsMuscular/Skeletal ConditionsChronic Health ConditionsOrthopeadicsSpeech PathologyRespiratory HealthDieteticsNutritionObesityGerontologyDisabilityWomen’s HealthMen’s HealthOther 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 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.