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.
Format: 04 0000 0000.
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 +
Are you available to work on the weekends time to time?
*
Yes
No
Have you worked with any other telehealth platform in the past 12 months?
*
Yes
No
Do you have a minimum of 6 months' experience as a GP registrar (on any pathway, including ACRRM)?
*
Yes
No
I am a VR/Non VR GP
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
If you have worked with a telehealth platform, please list all telehealth platforms you have worked with. Otherwise, write N/A.
*
Do you have experience in conducting weight loss management and prescribing GLP-1 medications?
*
YES
NO
If you have answered "No", are you willing to learn with appropriate guidance and training?
*
YES
NO
When are you planning to start?
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Your updated CV
*
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