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Title

First Name *

Last Name *

Email *

Phone Mobile *

Provider Number (if applicable).

State *

Region % of time
Please indicate below the percentage of your working time spent in each of the listed locations? *

Please type your responses in PERCENTAGES in the spaces provided. Your answers must add to 100%

% of your working time

A capital city

Another major city or metropolitan area

Regional town

Rural / Remote area

Total (must sum to 100%) 0

Primary HCP Type *

Specialty therapy area

Special interests

Job Title

Business Phone

Main practice suburb

Main practice postcode

Workplace / s

Work-setting % of time
What percentage of your time is spent working in each of the following settings? *

Please type your responses in PERCENTAGES in the spaces provided. Your answers must add to 100%

% of your working time

Public hospital / clinics

Private hospital

Specialist private rooms / practice

Community facility, clinic or service

Clinical trials / research

GP or Family Practice – Corporate Centre

GP or Family Practice – Group practice

GP or Family Practice – Solo

Other (please specify)

TOTAL (must sum to 100%) 0

INFORMED CONSENT – ADVERSE EVENTS STATEMENT If an adverse event(s) is identified, are you willing to waive anonymity and confidentiality for the purpose of follow-up on the adverse event(s) only? *

Yes — I agree to share my contact details for AE follow-up

No — I wish to remain anonymous for AE reporting

Password

Password must have at least 1 uppercase (A-Z), 1 lowercase (a-z),1 digit (0-9) and 1 special character. (Do not use these special characters #$%&]+=?)

Confirm Password

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