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Individual – General Practitioner Membership Form

Individual – General Practitioner Membership Form

About Us Membership Individual – General Practitioner Membership Form

Please complete all mandatory fields marked with an *

Title *

Name *

First

Last

Gender

Contact Phones and Email

Phone Number - Mobile

Business Email *

Personal Email

Preferred Email Address *

Phone Number - Business

Phone Number - Personal

Fax Number - Business

Fax Number - Personal

Business Address (For inclusion in ACT Health Services Directory)

Organisation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Personal Address (For office use only, not for publication)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Preferred Contact Address *

Clinical/Practice

Primary Practice / Organisation *

Other Practices / Organisations

RACGP Number

ACRRM Number

Special Interests (please select relevant options)

Adolescent - Youth Health
Aged Care
Alcohol/Other Drugs
Aviation Medicine
Diabetes
Diving Medicine
Health Promotion
Indigenous Health
Medical Education
Mens Health
Mental Health
Minor Surgery
Obstetrics
Occupational Medicine
Pain Management
Pallliative Care
Public Health
Research
Respiratory Medicine
Sexual Health
Sports Medicine
Travel Medicine
Womens Health

Special Interests (Other)

Languages Spoken

Health Services Directory (personal details will not be provided)

Include my details in the directory

Yes
No

Should you wish to provide your contact details to the ACT Health GP Liaison Unit, please contact the GPLU at gpliaison@act.gov.au.

By submitting this form, I agree to accept the Constitution of Capital Health Network.

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Contact Us

Contact Us

Phone

02 6287 8099

Fax

02 6287 8055

Email

Reception: reception@chnact.org.au

Media: media@chnact.org.au

Address

Address

2/1 Geils Ct, Deakin ACT 2600

Postal address

PO Box 9, Deakin West ACT 2600

ABN: 82 098 499 471

Opening hours

Monday-Friday, 9am-5pm

We respect the Aboriginal people of this region as the Traditional Custodians and cultural knowledge holders of this land.

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