Credentialing and Scope of Practice Application Form (QLD) - New Application

Application for appointment and scope of clinical practice as an accredited practitioner
  • Personal and Contact Information

  • (for Hospital invitation list)
  • Professional Practice Details

  • Professional Registration Details

  • Professional Indemnity

  • * This information is required to assess an application for scope of clinical practice and will only be used by Townsville Day Surgery for such purposes. Information provided will not be disclosed otherwise.
  • Detail the scope of Clincal Practice Requested (Not applicable to Surgical Assistants)

  • Other Clinical Practice Sought (Not applicable to Surgical Assistants)

  • Referees

  • Primary Undergraduate Qualification

  • Postgraduate Qualifications, Degrees, Diplomas College or Professional Qualifications

  • Professional Development over past 3 years - Please include any research activities, funded projects and quality assurance activity.(List below or attach CV)

  • Current Public Hospital Appointments (List below or attach CV)

  • Current Scope of Clinical Practice at other Private Hospitals (List below or attach CV)

  • Details of all Health Care related employment within the last 10 years (List below or attach CV)

  • Declaration and Authority

    I authorise the Townsville Day Surgery, its employees, officers and the Medical Advisory Committee, to obtain information on an annual, or as necessary, basis from the registration body/indemnity insurance organisation as nominated in this application, regarding the currency of my registration/membership of that body/organisation.
    I authorise the Townsville Day Surgery to include my practice details in any Hospital Specialist Directory.
  • Drop files here or
    Please attached a copy of your CV below:
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Please DO NOT enter the Townsville Day Surgery premises if you are unwell, have a temperature, cough or cold. Where possible, pre-admission forms can be completed online via the “pre-admit” link.