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IUIH Uniform Shop

Doctor/Clinic Stamp Order Form

Example

Information For Stamp

Dr Jane Doe

Line 1*

FRACGP, FAFPHM

Line 2*

Provider No: 123456HY

Line 3*

Moreton Aboriginal & Torres Strait Islander Community Health Service

Line 4

322 Oxley Ave, Margate QLD 4019

Line 5*

Ph: (07) 3480 8100 Fax: (07) 3283 8510

Line 6*

First name*

Last name*

Email*

Is this to be delivered to a MATSICHS site?*

Yes

No

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