Further information: 1300 134 111 | ClinicalLabs.com.au

Surgical Audit Program

CPD POINTSLAST CHANCE FOR CAT1 RACGP & ACCRM POINTS THIS TRIENNIUM

CL-HIS-0002 - Surgical Audit DL Flyer.indd 1 1/02/2016 12:06:45 PM

Further information: 1300 134 111 | ClinicalLabs.com.au

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Title: First Name:

Last Name:

Practice Address

Work From Additional Clinics:

Email Address:

Phone:

College:

RACGP QI & CPD/ACRRM Number:

Provider Number:

Practitioner Classification:

□ Dermatologist

□ General Practitioner

□ General Practitioner (with skin cancer work)

□ General Surgeon/Plastics

□ Skin Cancer Practitioner

Use of Dermoscopy:

□ None □ Low □ Medium □ High

To register please complete the form below

□ RACGP

□ Yes

Fax:

□ ACRRM

□ No

*Once your registration has been received special Surgical Audit Request Forms will be sent to your practice

(03) 9538 6760

skinaudit@clinicallabs.com.au

Attn: Emma Hofmann Australian Clinical Labs, 1868 Dandenong Rd, Clayton VIC 3168

Please send completed form to:

CL-HIS-0002 - Surgical Audit DL Flyer.indd 2 1/02/2016 12:06:46 PM