Join a Network | Agency for Clinical Innovation

Join the Network

Phone (main): *

Enter your main phone number. This may be a home, mobile or work number.

Phone (alternate):

Enter an alternate phone number.

Suburb/State/Postcode: *

Application

I would like to join as a: *

Health Professional
Consumer

Network

Select the network you would like to join: *

If you would like to join multiple networks please note these in the comments field below.

Other Information

Hospital/Organisation:

Enter the main hospital you are associated with (if any). A list of options will appear as you begin typing.

Local Health District:

Enter the Local Health District in which you are located.

Are you of Aboriginal or Torres Strait Islander origin?

Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal and Torres Strait Islander
No

Please select any categories that apply to you:

Comments:

Please outline your interest or experience in areas relevant to the network selected above, or any other comments you may have.

Notifications

Mailing List:

I would like to be added to the ACI newsletter mailing list

News:

I would like to be notified of network specific news

Consent

Please confirm: *

I consent to my name and organisation (where applicable) being provided to key stakeholders (such as Local Health Districts) of the ACI when requested. No contact information will be provided without my permission.

Join the Network

Contact Details

Application

Network

Other Information

Notifications

Consent

Nuclear Medicine Network

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