New Clinician Details

Full Name(Required)

As registered with AHPRA

Phone Number(Required)

Email(Required)

Postal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact(Required)

First and Last Name

Emergency Contact Phone(Required)

Bank Details(Required)

Name BSB Account Number

ABN(Required)

Entity Name(Required)

Current Provider Number(Required)

Prescriber Number(Required)

AHPRA Registration Number(Required)

Upload Certificate of Insurance(Required)

Max. file size: 1 GB.

Insurance Provider(Required)

Expiry Date(Required)

Photo ID(Required)

Max. file size: 1 GB.

Are you a Radiology Contrast Doctor?(Required)

Yes

ALS Certificate(Required)

Max. file size: 1 GB.

Clinician Signature(Required)