Clinical Lead in ED Ultrasound Registration Form
Please read the ‘Clinical Lead in ED Ultrasound’ drop down before completing the form. For the purposes of the Clinical Lead in ED Ultrasound Forum, there should be a maximum of two Clinical Leads per hospital, and each Clinical Lead will need to complete a separate registration form.
Name
*
Title
First Name
Last Name
Your Email
*
Phone Number
How many sites are you the Clinical Lead in ED Ultrasound?
*
1
2
3
4
Hospital Name
*
Please upload DEM verification (pdf or word doc, jpg,png)
*
Upload a File
Files must be below 100MB each.
Cancel
of
Hospital Name
*
Please upload DEM verification (pdf or word doc, jpg,png)
*
Upload a File
Files must be below 100MB each.
Cancel
of
Hospital Name
*
Please upload DEM verification (pdf or word doc, jpg,png)
*
Upload a File
Files must be below 100MB each.
Cancel
of
Hospital Name
*
Please upload DEM verification (pdf or word doc, jpg,png)
*
Upload a File
Files must be below 100MB each.
Cancel
of
I am a:
*
FACEM
Trainee
Other
Ultrasound Qualifications:
*
CCPU
DDU
Other
Which CCPU modules have you completed?
*
0/250
Select your location:
Please Select
Queensland
New South Wales
Victoria
Tasmania
South Australia
Western Australia
Norther Territory
Australian Capital Territory
Aotearoa New Zealand
Other relevant information to support application.
0/250
Submit
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