Describe your practice

Step 1: Who Are You?

Select one or more that best describe you

Patient or family member with a story to share

Clinician or healthcare professional

Researcher or academic

Media or journalist

Health organisation, foundation, or association

Corporate or philanthropic funder

Government representative or policymaker

Other (please provide details in Step 3)

Professional Profile Selected

I am a medical or health professional

Step 2: Contact Information

Your Professional Profile Selected

First Name

Last Name

Email

Phone Number

State / Territory

Preferred Method of Contact

Please create your own user name and password. This is a verification process for this campaign and also helps us manage the various partnerships.

Username

Password

Address

Suburb

City

State

Phone

Postcode

Country

Step 3 Option A: How Would You Like to Be Involved?

Option A – For Patients / Families / Clinicians

Please describe your experience or story (max 500 words)

Have you previously raised this issue with any health authority?

Yes

No

Would you like to be part of future research or forums?

Yes

No

Would you be open to speaking publicly or anonymously?

Yes, publicly (with name and/or photo)

Anonymously

Not sure yet — please contact me

Step 4: Consent and Privacy

AMN is committed to protecting your privacy. Your information will be handled confidentially and used only to contact you regarding this initiative.

View Privacy Policy

I consent to being contacted by AMN regarding this initiative

I understand my data will be stored securely and may be anonymised for research purposes

Step 3 Option B: For Organisations / Foundations / Corporates

Partnership and Support

What type of partnership are you interested in?

Describe your organisation’s focus or how you wish to contribute

Step 3 Option C: For Media / Researchers / Government

Collaboration and Insights

Area(s) of interest

What would you like to discuss or propose?

Step 3: Please provide details on your selection from Step 1

Provide Details Here

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National Patient & Clinician Engagement Hub