Polio Australia is the only national peak body representing Australia’s polio survivors. We are committed to standardising polio information and service provision across Australia so that all polio survivors have access to appropriate health care to best manage their chronic condition.

Polio Australia works with a range of treating health professionals to promote activities that raise awareness of the late effects of polio and/or post-polio syndrome through continuing professional development and patient education.

This website can be accessed by both health professionals and polio survivors to provide a broad range of online information and resources to help identify, diagnose, and manage the late effects of polio and/or post-polio syndrome.

However, many polio survivors still report great difficulty in obtaining correct diagnosis and treatment for polio-related problems. Therefore, both treating health professionals and polio survivors are keen to find practitioners who have some knowledge of and/or experience in working with polio survivors.

If you are interested in being included on Polio Australia’s Health Professionals Register, please add your details below.

For further information, please email [email protected] or phone 03 9016 7678.


* indicates a required field

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?  YesNo

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.


After submitting the form you should see a message in a box with a green border saying “Your registration was submitted successfully. Thanks.”, and you will be re-directed to a “thank you” page. If you instead receive this message: “One or more fields have an error”, please check your entries (particularly ensure that all required questions (those marked with *) have been answered) then resubmit the form.

If you strike a difficulty in submitting this form that you cannot resolve, please contact us by phone or email, or by completing our contact form, to let us know about the difficulty you experienced.