Research Affiliate Membership Form

eviDent Research Affiliates are eviDent DPBRN members who voluntarily respond to eviDent surveys and participate in retrospective studies by allowing members of eviDent project teams to attend their practice and collect relevant data.

Membership details

• Membership is free
• Confidentiality is maintained as data collected will be kept only on the eviDent database and will not be distributed to other organisations without permission

Benefits

• Opportunity for involvement in research, without being ‘hands-on’
• Regular eNews and invitations to attend professional networking events
• Access to project information and results
• Access to a ‘members’ only’ section of the eviDent website
• Opportunity to bring research findings into effect more rapidly
• Opportunity to influence policy
• Continuing professional development opportunities
• Opportunity to suggest and develop research projects

Register your interest below.

Please complete all required fields!

1. Personal Information
2. Title*
   DrA/ProfProfMrMsOther (please specify)Please make a selection
3. Other*
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4. Full Name*
   Please enter your full name
5. Position*
   Please SelectPractice ManagerDental AssistantDental HygienistDental TherapistOral Health TherapistDental ProsthetistRetiredOther (please specify)Please make a selection
6. Other*
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7. Email Address*
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8. Phone Number*
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9. Mobile Number
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10. Fax Number
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11. Postal Address*
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12. Suburb*
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13. State*
    ** Please Select **VictoriaNew South WalesQueenslandAustralian Capital TerritorySouth AustraliaWestern AustraliaNorthern TerritoryTasmaniaPlease make a selection
14. Postcode*
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15. Password

    Enter a password to use when your membership is approved.

    You will use your email address and this password to access the members area.
16. Password*
    Please enter a password!
17. Verify Password*
    Retype the password!
18. Declaration
19. I declare that:*
    a. I undertake to comply with eviDent’s policies, directives and all relevant legislation. I understand that failure to do so could lead to the possibility of termination of membership from eviDent;Please tick the boxes.
20. I declare that:*
    b. I will work with the project team and abide by the relevant project consent forms when participating in an eviDent project;Please tick the box
21. I declare that:*
    c. (Where applicable) I have the permission of the practice owner(s) to allow eviDent researchers access to data from my practice.Please tick the box
22. Send Application
23. *
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