Capital Health Network

Capital Health Network

Application for GP Class Membership

Please complete all mandatory fields marked with an *

Contact Phones and Email

Business Address (For inclusion in ACT Health Services Directory)

Personal Address (For office use only, not for publication)

Clinical/Practice

Health Services Directory (personal details will not be provided)

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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