Type of Applicant

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Type of Applicant

Please select ONE from the list below:

I am a medical student
I am a registered medical practitioner
I hold a Fellowship in aesthetic/cosmetic medicine - Medical Practitioners who hold a fellowship in aesthetic/cosmetic medicine may apply for equivalence recognition and be considered eligible for CPCA Fellowship.
I have an intention to (or an interest in) enrol(ling) into the Graduate Certificate in Cosmetic Medicine, in the immediate future.

Type of Applicant*

Please select the best match.

I am a medical student
I am a registered medical practitioner
I hold a Fellowship in aesthetic/cosmetic medicine with another College

GCCM Enrolment

I have an intention to enrol into the Graduate Certificate in Cosmetic Medicine, in the immediate future.

How did you hear about the CPCA?*

Select an option from the drop-down list below.

Applicant's Details

Personal details must match the record contained within AHPRA Medical Register. Click HERE to check.

Current Medical Registration No. (in full)*

Title*

First Name*

Middle Name

Last Name*

PRIMARY CONTACT DETAILS

These details are NOT published anywhere. Once you activate your login to the member website area, you will be able to update your public profile for use with the Find-a-Doctor website section (Full Members & Fellows only).

Mobile Phone #*

Business Phone #

Preferred Email Address*

Re-enter Email Address*

Address Line 1*

Address Line 2

SUBURB*

STATE*

COUNTRY*

POSTCODE*

Organisation

If applicable.

Image of passport or Australian drivers licence for ID purpose*

Accepted file types: jpg, png, pdf, gif, jpeg, Max. file size: 5 MB.

Head & Shoulders Photograph*

Processing of application may be delayed where this is missing. Do not go to any expense. This image will NOT be published anywhere.

Accepted file types: jpg, png, pdf, gif, jpeg, Max. file size: 5 MB.

MEMBERSHIP FEE PAYMENT - $825.00 Incl. GST

Receipt and paid tax invoice will be provided via return email.

Payment options:

Option #1: Credit Card Payment

Visa or Mastercard only. American Express is not accepted.
Please select option 1 and provide card details below.

Option 1 - Please tick the box below if you want to pay via credit card.

I will pay via credit card

Membership Fee + Credit Card Payment Fee (1.8%)

$825 + $14.85 = $839.85 Inclusive of GST

Price:

Total

Membership fee + credit card payment fee

$ 0.00

Credit Card

Card Details

Cardholder Name

Option #2: Bank Transfer

Account name: Cosmetic Physicians College of Australasia
BSB: 065-511
Account number: 10232364

Option 2 - Bank Transfer Payment Number/Receipt Number:

If you paid via bank transfer, please provide bank processing reference number here and upload bank transaction receipt below.

Upload bank transaction receipt

Accepted file types: jpg, png, pdf, gif, jpeg, Max. file size: 5 MB.

Option #3: Paid via a Special Offer

Please select this option if you have already registered and paid for a CPCA Special Offer which includes CPCA Corresponding Membership by providing your surname as a reference under option 3, and uploading a copy of your special offer payment receipt below.

Option 3 - Pre-paid via a Special Offer:

If you paid via a CPCA Special Offer, please provide your surname as a reference here and upload a copy of your special offer receipt below.

Upload Special Offer Receipt:

Accepted file types: jpg, png, pdf, gif, jpeg, Max. file size: 5 MB.

Applicant's Declaration

Please read the declarations you are making below. Tick all boxes to acknowledge you have read and accept the terms.

Declaration Tickbox - Become CPCA Member

I hereby apply to become a member of the Cosmetic Physicians College of Australasia.

Declaration Tickbox - Comply with CPCA guidelines

I agree to abide by and comply with the CPCA constitution, policies, protocols and guidelines

Declaration Tickbox - Comply with Regulations

I agree to abide by and comply with the *relevant state and federal laws, regulations and guidelines including those administered by governments, medical boards, and other organisations such as the Therapeutic Goods Administration, including those in relation to advertising.

Declaration Tickbox - CM Acknowledgement

I acknowledge that upon entry into the College, I am classified as a Corresponding Member until I apply to the Membership Committee for, and receive approval for, an upgrade to a higher membership level. (Further information will be provided in your Welcome Package).

Declaration Tickbox - CM Promotion Acknowledgement

I acknowledge that while I am a Corresponding Member, I am not permitted to promote my association with the College, digitally or otherwise. I am not permitted to use any form of wording, CPCA logo, and annual Certificate of Currency, etc., in my promotional material.

Declaration Tickbox - Info Permission

I give permission for the CPCA Committees to seek information from other parties to verify my good standing, in particular the Medical Defence Organisations and Medical Boards.

Insert full name:*

Date:*

Please note: It is unlawful to knowingly make a false declaration and is an offence which carries
significant penalty if prosecuted. In particular, but not exclusive to:

- *Health Practitioners National Law Act (2010 Commonwealth),
- Medical Board of Australia: Good medicine: a guide for doctors in Australia,
- Medical Board Australia: Advertising Guidelines,
- Medical Board of Australia: Guidelines for doctors performing cosmetic medicine and surgery,
- Medical Board of Australia: Technology Based Consultations,
- Local State and/or Territory Laws (Relevant Poisons Acts in the principality of your practice),
- Therapeutic Goods Act (Commonwealth)

Click here to view the Membership Information Booklet. Includes a copy of the College Constitution, Policies & Guidelines.

Your application is subject to approval/acceptance by the Membership Committee. Processing may take up to one business day. A tax invoice/receipt and welcome package will be sent via email. Thank you.

Please ensure that you have answered all the required fields and uploaded all the required documents before clicking the "Submit" button.

CPCA Membership Application

Type of Applicant

Applicant's Details

PRIMARY CONTACT DETAILS

MEMBERSHIP FEE PAYMENT - $825.00 Incl. GST

Payment options:

Option #1: Credit Card Payment

Option #2: Bank Transfer

Option #3: Paid via a Special Offer

Applicant's Declaration

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