Chronic MSK Pain and Acupuncture Audit Registration Form

Chronic MSK Pain and Acupuncture Audit Registration Form
Personal Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Postcode of your primary place of work*
AHPRA number*
Contact Details
Mobile phone number*
Preferred number for contact
Email*
Preferred email for contact
QI&CPD
This activity is approved by the RACGP for the following CPD activity types:

If you are a member of the RACGP, AMAC will upload your CPD hours for you.

If you are a member of another CPD home e.g. ACRRM, you may self-record these hours on completion of the activity.
I am a member of*

RACGPACRRMOther
RACGP number
Type in your RACGP number e.g. 123000
You will need to self record your CPD hours for this activity.

You will be sent a certificate stipulating the hours in each CPD activity type on completion of the activity.
Enrolment Dates
Enrolment for the audit
- Opens at 9am (AEST) 10 April 2023, and
- Closes at 5:00pm (ADST) 30/11/2023
Please Note: Enrolments will not be accepted outside these dates.
Cost: $300

GST included
Payment Options*

Electronic TransferCredit Card
Electronic Transfer:

Account Name: Australian Medical Acupuncture College
BSB: 084-484 Account No: 551553074
* Please use your full name as reference
Credit Card

For phone payments using your credit card, please contact Lisa Williams (Administrator) on 0428 850 771.

NB: email is not secure, do NOT sent credit card details by email.
Signature*

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Date*

DayMonthYear
Should be Empty:

Personal Details