Medical Centre Registration Form

* Medical Centre Name
* Address
* Town/City
 		Post Code
* Telephone Invaild telephone number
 		Fax
* Email Invaild email format
Website
* No. Doctors Invaild number
 		* No. Nurses Invaild number
* Commenced Trading     Invaild Date

Facilities Check List

Parking Family Medical Practice Disabled Access Immunisation Radiology Blood Pathology Collection Dentistry Physio Treatment
Parking Family Medical Centre Disabled Access Immunisation Radiology Blood Pathology Collection Dentistry Physio Treatment
Acupuncture A & E Ante-Natel Care Medical Examinations Smoking Cessation Dietary Obesity Occupation Health Podiatry
Acupuncture A & E Ante-Natel Care Medical Examinations Smoking Cessation Dietary Obesity Occupation Health Podiatry
Other (specify)
Special Instructions
Where would you like your screen installed?
Est. Annual Footfall
* Contact Name
 		* Position
I agree to the terms and conditions and am duly authorised to sign for the grantor

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