Capital Health Network

About Us Membership Organisation Membership Form

Please complete all mandatory fields marked with an *

Membership Package *

Primary Organisation Representative

Title *

Name *

First

Last

Organisation(s) *

Position *

Phone Number - Mobile

Email Address *

Organisation Details

Business Name *

Phone *

Website

ABN *

Health Link Identifier

Physical Address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mailing Address

Same as physical address? *

If the mail address isn't the same as the physical address, please fill out the fields below

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Number of full time equivalent staff employed

General Practitioners

Nurse Practitioners

Practice Nurses

Allied Health Professionals

Others

Hours of operation

Monday to Friday

Weekends

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Phone

Organisation Membership Form

Organisation Membership Form

Primary Organisation Representative

Organisation Details

Physical Address

Mailing Address

Number of full time equivalent staff employed

Hours of operation

Menu

Quick Links

Contact Us

Phone

Email

ABN