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New Registration

IMPORTANT: Do not complete the following registration form if you are a CICM Fellow or trainee as CICM is already your CPD Home. If you are unsure about your login credentials or have any inquiries, please contact the College for assistance.

If you need assistance with logging in , o r T w o F a c t o r A u t h e n t i c a t i o n (2 F A ), please view this short guide.

Personal Details

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crm_contact_id

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adsso_user

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user_role

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Username

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Upload profile image

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

Name*

Prefix First Middle Last Suffix

Email*

Also Known As

Previous Surname

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Pronoun

Medical registration details

Medical Registration Authority

Medical Registration Number

Register for CICM to be your CPD Home (For non-members only)

By selecting "I confirm" you are registering for CICM to be your CPD Home. You will receive an automatic email confirming your registration this and will also receive an invoice once confirmed by our CPD department.

I confirm that CICM will be my CPD Home

Please confirm that your scope of practice aligns with intensive care medicine.

I confirm that my scope of practice aligns with intensive care medicine

Gender*

Self-Described*

Date of Birth*

Country of Birth

Country

Country of Residency*

Country

Citizenship*

Country

GST Nomination*

Contact Number*

Mobile Number

Fax

Website

Facebook

Twitter

Professional Bio

Do you identify as Aboriginal, Torres Strait Islander, Māori, and/or Pacific Islander?*

Yes

No

Prefer not to say

Member of another College?*

Yes

No

Please select all that apply*

Aboriginal

Torres Strait Islander

Māori

Pacific Islander

College Affiliation

Medical College Name*

Member ID/ Number*

Member Type*

Primary Examination Date

DD slash MM slash YYYY

Fellowship Examination Date

DD slash MM slash YYYY

Postal Address Details

Address*

Street Address Address Line 2 City State Postal Code Country

Billing Address Details

Same as Postal Address

Address

Street Address Address Line 2 City State Postal Code Country

Share information to other fellow

You can opt to share your information with other CICM Fellows. Any information you opt to share will be visible in the Peer Fellow module

Share information to other fellow

Email

Contact number

Current work location

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Select this checkbox to allow other CICM Fellows to chat with you via the online chat

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Phone

This field is for validation purposes and should be left unchanged.

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