CESPHN Pharmacist Immunisation Newsletter
Pharmacists
working in the CESPHN region can complete this form to subscribe to our monthly Pharmacist Immunisation Newsletter and stay up to date with the latest information and any upcoming events.
Pharmacist details
Salutation
Please select...
Mrs
Ms
Miss
Mr
Preferred Name
First Name
Middle Name
Last Name
Gender
Please select...
Female
Male
Non-binary
Other
Prefer not to say
Other
Job Title (if different to Pharmacist)
AHPRA Registration Number
Work number (work phone)
Mobile number (personal number)
Work Email
Personal Email
Primary employment - Name of pharmacy where you are currently employed
Secondary employment (if applicable) - Other pharmacy/pharmacies where you are currently employed
Additional Qualifications
Please select any additional qualifications you hold?
Aged care on-site pharmacist (ACOP)
Authorised immuniser
Residential medication management review (RMMR)
Home medicines review (HMR)
Other
None
Other: