Doctor Enquiry

Full Name *

Phone number *

Email address *

What type of practitioner are you? * Select... General Practitioner Fellow General Practitioner Registrar Specialist Fellow Specialist Registrar Nurse Practitioner Other

What state are you based in? * Select... WA NSW VIC QLD SA NT ACT TAS Other

Other State *

Please provide your AHPRA registration number. *

Are you currently under a 10-year moratorium? * Select... Yes No

Roughly, how many days per week are you able to consult? * Select... 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days

Roughly, how many hours per week are you able to consult? * Select... Below 10 hours 10 - 20 hours 20 - 30 hours 30+ hours

What days of the week can you consult? *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Varies

Please select the type of shifts you can offer. (NOTE: all options refer to within your own time zone) *

Early morning shifts Within standard business hours Evening/late night shifts Overnight shifts Weekends Varies

Do you have access to PRODA? * Select... Yes No Unsure

Are you limited to the amount of provider numbers you can have? * Select... Yes No Unsure

Anything else we should know?

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