Service Providers Directory Application Form

Please complete the form below if you would like your continence related service to be considered for inclusion on Continence Health Australia's Service Providers Directory. You may be contacted if any details need clarification. You will be notified if and when your service has been added to the Service Providers Directory.

About the Service

Name of your Service	Appointment Phone Number This is the number that will be displayed on the website.
Phone Service ABN/ACN	Fax Number Website
Service Email Please note that this email address will be used for requesting updates about services offered by your service. If you would also like this email address published on the directory, please indicate below: YesNo

Address

Mailing Address

Additional Address Line (or PO Box)

Postal Street Address

Suburb

State

Postcode

Physical Address

Additional Address Line (or PO Box)

Street Address

Suburb

State

Postcode

The physical address will appear on the website. You may omit the street address if required.

Directory Contact Details

First Name	Last Name
Phone	Mobile
Position	Correspondence Email

Authorisation

The information provided in this form is complete and accurate to the best of my knowledge. I grant permission for this information to be made available to the public by Continence Health Australia on the Service Providers Directory of the website www.continence.org.au

First Name

Last Name

Phone

Mobile

Position

Email

Additional Information

0-4 years	5-16 years
17 years	18-64 years
65 years or older

CDM	DVA	Home care package
NDIS	Private health insurance	Road trauma
Workcover	Other

Bedwetting	Bladder	Bowel	Catheter care (ISC)
Catheter care (IDC/SPC)	Pelvic floor	Pessaries	Toilet training
PTNS	Stoma care	Transanal irrigation	Other

Has real-time ultrasound	Hires bed alarms	Does urodynamics
Does video urodynamics	NDIS registered provider	Needs MAC ReferralMAC - My Aged Care
Needs medical referral

Colorectal clinic	Community health service
Continence service	Enuresis clinic
Gastroenterology clinic	Independent living centre
Men's health clinic	NDIS service
Nurse continence specialist service	Nursing service
Occupational therapist service	Paediatric continence service
Pelvic floor physio practice	Physiotherapy practice
Private continence service	Psychology practice
Sexual therapy clinic	Spinal service
Stomal therapy service	Support group
Telehealth service only	Urogynaecology clinic
Urology clinic	Women's health clinic
Other