Clinician Onboarding Form

Personal Details / Contact Information

General Personal and Contact Information

First

Last

Prefered way you'd like Receptionists to refer to you to patients (if other than standard Dr XXX).

Date of Birth

Address

Number and Street

Suburb

State

Postcode

Country

Phone/Mobile

Emergency Contact Name

Emergency Contact Number

Relationship To Clinician

Professional Details

General Clinician Registrations and Required Licences

AHPRA Registration Number

Full Qualifications (As you want them to be displayed on business cards)

Medicare Provider Number Altona North

Medicare Provider Number Williamstown

PBS Prescriber Number

PRODA Account Number

Radiation Use Licence Number

Does this include Panoramic and CBCT?

Professional Indemnity Insurance Company

Member Number

Profile Details

Used for website information / patient information

Bio / Blurb

Photo of yourself

Choose File(s)

Would you like a dedicated work email address?

Text Input

@hobsonsbaydental.com.au

Initial Booking Preferences

These will be used as rough guides for reception staff when starting to fill your books. Free free to allocate as much time as you think will allow you to settle in whilst getting used to everything. These will remain fluid, and feel free to speak to reception whenever you feel like they might need some tweaking.

New Patient Exam / Clean

Existing Patient Recall

Exam/Consult Only

Broken Tooth / Filling

Toothache / Pain

Extraction

Crown Prep

Endo

If there's anything else relating to patient appointments that you feel may make your onboarding seemless and stress free, please comment here.

Uniform Details

You may wish to wear your own existing scrubs, however we are happy to provide 2 sets with logo/name embroidery if you'd like.

Alternatively, you may prefer a tunic or other style, if so please let us know.

Preferred Scrub brand (leave blank for no preferred or paste link to website for specific brand or style)

Scrub top size

Scrub bottoms size (leave blank for no bottoms)

Exact name you'd like embroidered

Preferred Colour Set 1

Preferred Colour Set 2

Financial Details

For payments and tax information.

ABN

Tax File Number

Bank Name

Name of Account

BSB

Account Number