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Provider name

Service provided

Name of practice (if applicable)

Legal trading name

Are you...Sole practitionerPart of the clinic group

Do you operate in more than 1 clinic location?YesNo

Email address

Contact number

Postal Address

Billing Address

Same as postal address

ABN

AHPRA registration number

Provider number (if applicable)

Prescriber number (if applicable)

HIP number (if applicable)

HPIOS number (if applicable)

Practice contacts