EXIT GP Link Registration Practice Details Please complete the form below. MedAdvisor will contact you with login details once your profile is complete. Please allow one week for this process. Please note: Email addresses for Practice and each GP must be different to enable setup. OK Question Title * 1. Practice Details Practice Name Practice Address Contact Name Phone Fax Email Address Booking system URL OK Question Title * 2. Business Details ABN Business Name OK Question Title * 3. Practice Manager Details Title First Name Last Name Email Address Mobile Number OK Question Title * 4. Script Renewal Pricing Pricing for first script in order (suggested pricing $19.95) Pricing for each additional script in that order (suggested pricing $5.00) OK Question Title * 5. Practice Banking Details Account Name BSB Bank Account Number OK Question Title * 6. Practitioner Details (please fill out for each practitioner joining) Prescriber Number Provider Number AHPRA Number Title First Name Last Name Qualifications Mobile Number Email Address OK Question Title * 7. Practitioner Details Prescriber Number Provider Number AHPRA Number Title First Name Last Name Qualifications Mobile Number Email Address OK Question Title * 8. Practitioner Details Prescriber Number Provider Number AHPRA Number Title First Name Last Name Qualifications Mobile Number Email Address OK Question Title * 9. Practitioner Details Prescriber Number Provider Number AHPRA Number Title First Name Last Name Qualifications Mobile Number Email Address OK Question Title * 10. I confirm that I have read and accept MedAdvisor's GP Link License Agreement Yes No OK DONE
