Primary Care team request form
Please use this form to request support from our Primary Care team.
Name
*
First Name
Last Name
Email
*
example@example.com
Direct phone number
Practice Name
*
Your role
*
LGA your practice is in
*
Please Select
Banana
Brisbane
Cherbourg
Goondiwindi
Ipswich
Lockyer Valley
Scenic Rim
Somerset
South Burnett
Southern Downs
Toowoomba
Western Downs
Outside of PHN region
Type of support you are requesting
*
GP Liaison Officer
Primary Care Liaison Officer
I'm not sure
Please provide information about your enquiry or support request
*
Please write the article in the third person (ie. use your company name, don't say 'we')
Please verify that you are human
*
Submit
Should be Empty: