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Are you currently practising as a healthcare professional? *

Yes, Currently practising

Not currently practising but likely to in the future

Retired

Title

First Name *

Surname *

Fullname

Fullname1

Gender *

Date of birth (dd/mm/yyyy) *

Email *

Alternate Email

Mobile number (eg. 0412345678)

Alternate phone number (eg. 0345678901)

Primary practice location

Suburb

Postcode *

Country *

Discipline *

Field of practice (Choose up to 3)

1
2
3

Years of experience

Main Hospital or Clinic

Australian Health Practitioner Regulation Agency (Ahpra) Number (e.g. MED0000932846)

Password *

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Password must have 8 characters – at least 1 uppercase (A-Z), 1 lowercase (a-z),1 digit (0-9) and 1 special character. (Do not use these special characters #$%&]+=?)