registration form - FPWA Sexual Health Services
registration form - FPWA Sexual Health Services
registration form - FPWA Sexual Health Services
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SH&FPA Certificate in<strong>Sexual</strong> and Reproductive <strong>Health</strong> for Medical Practitioners – 201370 Roe St (cnr Lake St) Northbridge, Western Australia 6003 Phone: (08) 9227 6177 Fax: (08) 9227 6871 www.fpwa.org.auThis Certificate course covers sexual and reproductivehealth issues for both women and men at a postgraduate level.The course is accredited for CME points by the RACGPand ACRRM. It is held in high esteem and thought to bevery practical in nature, giving participants the confidenceand skills to work at a high level in this area. Different tothe DRANZCOG, the course focuses on primary careaspects of sexual health, a core aspect of both generalpractice and specialist training in obstetrics andgynaecology.Those who might have a special interest in completingthe Certificate are GP Registrars (where the skillsobtained in this course cover many of the objectives setout in the women's and men's health core curriculums),general practitioners and those who wish to work incommunity health centres, or family planning clinics.Course Content – 5 day theory Female and male reproductive physiology Contraception: in<strong>form</strong>ation on different contraceptiveoptions, both hormonal and non-hormonal, andmanagement of problems associated with their use. Management of unplanned pregnancy, includingmedical, psychosocial, counselling and legal aspects Diagnosis and management of sexually transmittedinfections Cervical and breast screening Menopause management Management of couples with subfertility Office gynaecology: menstrual problems, vulvaldisorders, fertility etc Men's sexual health: office urology, male sexualdifficultiesAdditional Info Some pre-reading is required. It isstrongly recommended to purchase, Reproductive and<strong>Sexual</strong> <strong>Health</strong>: An Australian Clinical Practice HandbookThis book and other resources (brochures/pamphlets,etc)are available from the <strong>FPWA</strong> Libraryhttp://www.fpwa.org.au/resources/Resource-Purchasecatalogue_2012.pdfIf attending five day theory, Contraception: An AustralianClinical Practice Handbook, Third Edition is included (aslong as supply lasts)2013 Course Dates – 8.30am to 5.00pm daily at <strong>FPWA</strong>27 to 31 May 201328 October to 1 November 2013Please note that the course may be cancelled if thereare insufficient enrolments by the last date for<strong>registration</strong>s. If this occurs, participants will be notified assoon as possible, and a full refund will be made. Pleasedo not book flights until you receive course confirmationemail (a minimum of four weeks prior to course).If you cancel your enrolment:Please see attached <strong>FPWA</strong> Policy on Course Bookings,Fees and Refundshttp://www.fpwa.org.au/educationtraining/bookingsrefunds/Option One - $1480 (5 day theory and 6 clinicalsessions at <strong>FPWA</strong> clinic - non-refundable aftercompletion of theory component)Designed for doctors who want to obtain the SH&FPACertificate in <strong>Sexual</strong> and Reproductive <strong>Health</strong>.Participants must complete: Pre-course reading - approximately 4 - 5 hours A five day theoretical component, includingassessment on the Friday afternoon A minimum of seven clinical sessions consisting ofthree and a half hours each, one being in Men's<strong>Health</strong> (Men’s <strong>Health</strong> session – additional fees mayapply). Sessions are to be arranged at times suitableto the applicant and <strong>FPWA</strong>. Clinical practicum iscompleted after theory and must be finished withintwo years. To organise your clinic dates, email theClinic Administration Officer,clinic.adminofficer@fpwa.org.auParticipants must have: Current Registration with the Medical Board ofAustraliaRescheduling of clinical practicums, afterconfirmation, will incur a fee of $80.00Please note: GP Registrars who plan to do the threemonth term at <strong>FPWA</strong> do not need to enrol for theclinical attachment.Option Two - $1000 (5 day theory)Designed for participants who wish to obtain up to datetheoretical knowledge in the field of sexual health. Thisoption consists of the five day theoretical componentonly. A Certificate of Attendance is issued on completionof the course.Option Three - $250 each Module 1 – 4 (whole daymodules). $125 Module 5 (half day)Doctors may choose to complete individual modulesaccording to their needs or areas of interest. Thesemodules may be accredited towards the Certificate in<strong>Sexual</strong> and Reproductive <strong>Health</strong>, as long as alltheoretical modules are completed within one year fromthe commencement of the first module.CME Points40 pts – Category 1 (subject to RACGP approval)Venue:70 Roe St (cnr Lake St) Northbridge, Western Australia.The theory course is held at <strong>FPWA</strong> in the LectureTheatre – daily from 8.30am to 5.00pm.Supervised clinical practicum is held in the <strong>FPWA</strong> clinic.For further in<strong>form</strong>ation, please contact either:Dr Alison Creagh, Medical Educatoralison.creagh@fpwa.org.au ORMs Leza Bridges, Admin Support Officerleza.bridges@fpwa.org.au
SH&FPA Certificate in <strong>Sexual</strong> and Reproductive <strong>Health</strong> for Medical Practitioners - 2013REGISTRATION FORM and TAX INVOICEABN 15 275 099 026Please tick OPTION or INDIVIDUAL MODULES ONLY and please tick optional IMPLANON NXT workshop OPTION 1 The entire certificate course, with clinical supervision and assessment. (all costs are GST free)Cost $1480.00 (5 day theory, including 6 clinical practice sessions. Additional fees may apply forMen’s <strong>Health</strong> Session. Please note: Clinical practicum must be completed within 2 years) $ OPTION 2 Five day theory course alone. Cost $1000.00 $ OPTION 3Individual days/modules. As listed below.Cost per day/module (1 – 4) - $250.00 each. Cost Friday/module 5 - $125 $IMPLANON NXT workshop – 5.15pm to 7.15pm (no charge) – please tick (yes or no) YES – Wednesday, 29 May 2013 or YES – Wednesday, 30 October 2013 NO - I do not want to attend the Implanon NXT workshopOPTION 3 - INDIVIDUAL MODULES ONLY – Please tick the module/s you wish to attendGST free – TOTAL $ MONDAYWomen’s <strong>Sexual</strong> <strong>Health</strong> Across the Lifespan(Module 1) $250.00 $ TUESDAYContraception(Module 4) $250.00 $ WEDNESDAY Men’s <strong>Sexual</strong> <strong>Health</strong> Across the Lifespan(Module 3) $250.00 $ THURSDAY Office Gynaecology(Module 2) $250.00 $ FRIDAY<strong>Sexual</strong>ly Transmitted Infections(Module 5) $125.00 (morning session only) $(Final assessment will be held during the afternoon session)GST free - TOTAL $REGISTRATION DETAILSName: _________________________________gender_________QI&CPD Reference Number: _____________________________Preferred name for ID badge: _____________________________ **E-mail for confirmation & pre-reading: __________________Home Address:__________________________________________________________________________________________________________Work Place: ________________________________________________________________________________________________Suburb:____________________________Post code:__________Address: ____________________________________________Suburb:____________________________Post code:__________Home Ph: _________________ Mobile: __________________ Work Ph: _________________ Fax: ____________________Please let us know your current role - GP____ GP Registrar____ RMO____ other (specify___________________DATE YOU WILL BE ATTENDING: 27 – 31 May 2013 (<strong>registration</strong>s close 6 May 2013) Prices valid until June 2013 28 October - 01 November 2013 (<strong>registration</strong>s close 07 October 2013)If you are interested to register after the closing date, please contact Leza as there may be places availableThe theory course is held at <strong>FPWA</strong> in the Lecture Theatre – daily from 8.30am to 5.00pmPlease read <strong>FPWA</strong> course bookings, fees and refunds policy either attached or on our website: http://www.fpwa.org.au/educationtraining/bookingsrefunds/I have read the <strong>FPWA</strong> course bookings, fees and refunds. Signature______________________________ Date________To reserve your placement, please send this <strong>form</strong> together with full payment toLeza Bridges, <strong>FPWA</strong> PO Box 141 NORTHBRIDGE Western Australia 6865PH: 9227 6177 OR FAX to 9227 6871 or leza.bridges@fpwa.org.au or phone credit card details for payment.Please keep a copy for your records - This <strong>registration</strong> <strong>form</strong> is a Tax Invoice ABN 15 275 099 026Cheques to be made payable to “<strong>FPWA</strong>” OR please circle: Mastercard / Visacard payments accepted.Credit Card Number ___ ___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___ Exp ____ / ____Name as appears on Card _________________________________Signature____________________________________I (please circle) agree/do not agree to <strong>FPWA</strong> using any photos taken of myself during this course/workshop for the purposes of positivepromotion (eg; website, annual report).Signature _____________________________________ Date ________________________Prices valid until June 2013
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