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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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

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Phone

Fax

Email

Address