North St Ives Medical Practice
Onboarding Form
1. Personal Details
Name
*
Dr.
Mr.
Mrs.
Miss
Prefix
First Name
Middle Name
Last Name
Preferred Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
E-mail
*
Mobile Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Business & Contractor Information
Business Structure
Please Select
Sole Trader
Company
Trust
Entity Name
ABN:
Is your Entity address the same as your Home Address?
Yes
No
Entity Address (if different to Present Address above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Practice Preferences
Please confirm your regular consulting days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Session Times based on the above days
Areas of Clinical Interest:
Additional Qualifications or Certifications
Do you perform
Skin Checks
Biopsies / Excisions
Iron Infusions
Mental Health Plans
Immunisations
Other
Do you offer Telehealth
Yes - Phone & Video
Yes- Phone Only
No
Not Applicable
4. Compliance and Credentialing
Professional Category
GP
Other
Provider Registration Type
APHRA
Other
Registration Number (APHRA or other)
*
Health Professional Individual Identifier Number
*
PRODA RA Number
*
Medicare Prescriber Number
Do you have a Medicare Provider number for North St Ives Medical Practice?
Yes
No
Medicare Provider number for North St Ives Medical Practice
Insurance Details
Name of Insurance Provider
Your policy / member number
Current Expiry Date
-
Day
-
Month
Year
Date
I confirm my medical indemnity insurance covers all services provided at North St Ives Medical Practice, including procedures and telehealth.
Yes
No
5. Systems Access & Preferences
I have experience with Best Practice?
Yes
No
I require training on Best Practice?
Yes
No
Do you have Whatsapp?
Yes
No
I consent to being added to the practice Whatsapp group
Yes
No
I consent to offer repeat scripts to regular patients on stable medications for a fee, without an appointment
Yes
No
6. Profile & Marketing Information
Short Bio for the website and marketing collateral (Max 150 words)
Profile Photo (upload)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Consent to use photo and bio on website and promotional materials
Yes
No
7. Banking Details
Bank Name
Account Name
BSB:
Account Number:
8. Emergency Contact
Name:
Relationship:
Mobile:
9. Signature and Acknowledgement
Signature
Please sign above to acknowledge the information provided
Date
-
Day
-
Month
Year
Date
Save
Continue
Continue
Should be Empty: