2021 HPMI Group Membership

Please complete following form to become a HPMI Group Member.
You MUST answer question re Surgery name and contact
If you have not already done so please contact Tracy Hicks to discuss Group Membership 02 4913 8163 or email Tracy.Hicks@newcastle.edu.au
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COMPLIMENTARY MEMBERSHIP (click here) AVAILABLE TO GP Trainees, Health Students, Interns and Residents
INDIVIDUAL MEMBERSHIP (click here)

Question Title

* 1. Surgery Details

Surgery Name

Contact Person Name

Contact Email Address

Question Title

* 2. Surgery Name and Address

Surgery Name:

Surgery Address 1:

Surgery Address 2:

Surgery Address 3:

City/Town:

State/Territory:

Post Code:

Question Title

* 3. Phone Nos.

Business

Fax

Question Title

* 4. Preferred mail address (if different from above)

Address 1

Address 2

City/Town

State

Postcode