Health Practitioner - Expression of Interest

To submit your expression of interest to join myeden's clinician and clinic network please submit the required information in this form. Expressions of interest will be periodically reviewed, with outcomes communicated to your preferred email.

Email address (EOI outcomes will be sent to this email) *

Contact Details

First Name *

Last Name *

Phone Number *

Clinical Information

AHPRA Registration Number *

Health Profession *

State/Territory of practice *

Wold you like to participate in industry training to enhance your prescribing and product awareness skills? *

YesNo

Please describe your experience with prescribing alternative medicines *

Calendar Availability

Are you seeking (select one) *

1-5 hours per week6- 10 hours per week10+ hours per week

Consent and Authorisation

I agree that the information that I have provided in this form is true and accurate. *

I agree to the collection, storage and processing of the information in this form for the purpose of EOI form reviews and validation. *

Please sign here to indicate your consent. *

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