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* Required fields
You will need a medical certificate from the applicant's doctor or medical practitioner to complete this application.
Given Name *
Family Name *
Telstra home phone number *This will be the home telephone number that we will set up for Priority Assist.
This will be your 10 digit home phone number beginning with an area code
Telstra home phone number. This will be your 10 digit home phone number beginning with an area code
Email *This will be the email address that we contact you on.
Contact Number *This may be the number that we may contact the representative on
Email *This may be the email address that we may contact the representative on
How would a doctor/medical practitioner classify the medical condition? *Please select temporary (less than 3 years) or permanent (over 3 years).
If we require more information to process the patient's application, we may need to contact their doctor/medical practitioner. Please ensure these details are correct.
Given name *
Place of practice *This is the address of your doctor's/medical practitioner's rooms/practice.
Phone number *
Attach your medical certificate *Please attach the medical certificate that certifies the applicant's condition. You must include this to complete your application.
(File up to 4MB. Examples of acceptable files are .png .gif .jpg .tif .pdf .doc .docx)