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HCP
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Contact us

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First Name*

Last Name*

Email*

Phone Mobile*

State*

Regions you’re working in (please select all that apply)*

A capital city

Another major city or metropolitan area

Regional town

Rural / remote area

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HCP Type*

Specialty therapy area

Special interests

Job Title

Business Phone

Main practice suburb

Main practice postcode

Workplace / s

Please select the work settings where you practise (please select all that apply)*

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)

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If an adverse event (AE) is identified, are you willing to waive anonymity and confidentiality for that event 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 #$%&]+=?)

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+61 (0) 429 060 585
info@hurnmingbirdexpress.com.au
Level 4, 100 Harris St. Pyrmont. Sydney, NSW 2009

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