ACA Join Form

Name*

First Last

Date of birth*

DD

MM

YYYY

Are you of Aboriginal and or Torres Strait Islander origin?

Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander

Gender*

Female
Male

Ahpra Registration Number*

Professional Indemnity Insurer*

Guild Insurance
AON

Do you practise as a:*

Locum
Associate
Principal

Do you practice as:*

Locum
Associate
Principal

Where is your principle place of practice?*

Payment Preference*

Annual (pro-rata)
Monthly

An ACA staff member will contact you for your credit card details once your application is received.

Please note: for monthly instalment options, three months payment upfront is required on application. An ACA staff member will contact you for these details once your application is received. Applications will not progress until payment details are received.

Unfortunately monthly instalment options are not available for foreign members. An ACA staff member will contact you to discuss this further.

Contact Details

Postal Address*

Address Suburb State Postcode Country

Email*

Mobile phone*

Home phone

Main Clinic Details

Main clinic name*

Main clinic address*

Address Suburb State Postcode Country

Main clinic phone

Main clinic fax

Main clinic email address

If applicable

Main clinic website address

If applicable

Do you practise at a second clinic?

Yes
No

Please fill out the details for your second clinic.

Second clinic name

Clinic address

Address Suburb State Postcode Country

Clinic phone

Clinic fax

Clinic email address

If applicable

Clinic website address

If applicable

Do you practise at a third clinic?

Yes
No

Please fill out the details for your third clinic.

Third clinic name

Clinic address

Address Suburb State Postcode Country

Clinic phone

Clinic fax

Clinic email address

If applicable

Clinic website address

If applicable

Membership Category

Membership category - Please indicate*

If you selected Limited/Part-time please indicate number of hours practised per week

If you selected Academic and are practising part-time, please indicate number of hours practised per week.

Please provide details of study

Chiropractic Qualifications

Name of qualification*

Graduating Institution*

Year of graduation*

Further qualifications

Chiropractic Techniques & Areas of Interest

Chiropractic techniques - Please indicate what techniques you are skilled in:

Other techniques

Chiropractic areas of interest - Please indicate what areas you are interested in:

Neurorehabilitation
Sports & Exercise
Paediatrics
Pain Management
Wellbeing & Lifestyle Management

Languages spoken

Do you accept patients for:

Department of Veterans' Affairs (DVA)
Medicare Chronic Disease Management (CDM)
HICAPS
Third Party Insurers (i.e Workers Compensation)

Do you use X-ray facilities in your clinic?

Yes
No

Do you have an X-ray licence?

Yes
No

Do you have access for disabled patients at your clinic?

Yes
No

Do you provide after hours/emergency care at your clinic?

Yes
No

If yes please provide your emergency telephone number.

Do you comply with the CBA Code of Conduct for chiropractors?*

Yes
No

Have you had or are you aware of any malpractice claims against you?*

Yes
No

If yes please provide details.

Have you ever been convicted of a criminal offence?*

Yes
No

If yes please provide details.

How did you hear about us?*

Guild Campaign Email
Website
Mailout: Supporting our Everyday Heroes Brochure
Email
The Australian Chiropractor Magazine
Social Media
Word of Mouth

If word of mouth, please supply the name of the person who referred you.

Declaration by the Applicant

I agree to abide by the Code of Ethics of the Australian Chiropractors Association and to observe all rules and regulations in conjunction with the Company Constitution and any amendments that are made thereto.

I agree to uphold the principles and pay all dues of the Association, thereby assisting in accomplishing its objectives.

I hereby declare that all information provided in this application is true and I understand that any misrepresentation on my part whether willful or unintentional, may cause me to forfeit my membership of this Association.

Declaration*

I agree that in submitting this form, I hereby certify that all statements in this application for membership are complete and true.

Privacy Policy*

I agree that I have read and understood ACA's Privacy Policy and agree to ACA using and disclosing the information collected about me in accordance with the Privacy Policy.