MEDSAC Membership Application

Thank you for your interest in becoming a member of MEDSAC.

Please note that by submitting this membership/subscription form you are agreeing to abide by the MEDSAC Member Code of Conduct as specified on this website.

Doctor / Nurse Details:

Title :

First Name :

Last Name :

Email :

Phone :

Mobile Phone :

Address

Country :

Address :

City :

State or Province :

Zip or Postcode :

Details of Lead Clinician: Name / SAAT Service :

MEDSAC Doctor Advanced Applicants only. Advanced qualification that you hold: :

Please tick one option below.

MEDSAC - Doctor - $350 per annum

MEDSAC - Doctor Advanced - $350 per annum

MEDSAC - Associate - $290 per annum

MEDSAC - Nurse - $156 per annum

MEDSAC - Nurse Associate - $60 per annum

MEDSAC - Affiliate - $156 per annum

Message :

MEDSAC Affiliate Applicants only.

Please provide in the message box above - Details of Referee (fellow clinician)

Name, Phone, Email, Position

And answer: "What is your clinicial interest in the area of Sexual Assault medicine?"