NextClinic New Doctor Intake Form
Please continue filling out this form only if you have full AHPRA registration with no restrictions.
Full Name
*
First Name
Last Name
AHPRA registration number
*
Mobile Number
*
Please enter a valid phone number.
Prescriber Number
*
Email
*
example@example.com
Your qualifications such as (MD/MBBS etc)
*
Your PGY year
*
PGY4
PGY5 and above
How many hours per week are you available to work?
*
8 hours
9 hours +
Do you have at least 12 months of combined experience in one or more of the following specialties? Please tick all that apply:
*
General Practice
Telehealth
General Medicine (including specialty rotations)
Emergency Medicine
When are you planning to start?
*
-
Day
-
Month
Year
Date
Your CV
*
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