COPD-X Handbook Hard Copy Request Form

To request a hard copy of the COPD-X Handbook, please provide you details below. Please note that supplies are limited, and request will be fulfilled on a first-come, first-served basis.

Your Details

Title

Please select... Mr Ms Miss Mrs Dr Prof A/Prof Prefer not to say

First Name

Last Name

Email

Mobile

Primary affiliation/organisation

I wish to be notified when the COPD-X Plan is updated on copdx.org.au and receive a new PDF of the latest guidelines. 

Your Location

Building Name (e.g. village/estate/hospital/business name)

Number and Street Name

Suburb/Town

State

Please select... NSW VIC ACT NT WA QLD SA TAS Other

State: Other

Postcode

Country

Please select... Australia New Zealand Other

Country: Other

DONOR ID

Which of the options below best describe you?

Which of the options below best describe you?

I'm a health professionalI'm in research/academiaI'm living with a lung conditionI'm caring for someone with a lung conditionI'm an interested member of the community

You indicated you were living or caring for someone with a lung condition, to help support you best, please select your condition(s):

Alpha1 Antitrypsin Deficiency	Asthma	Bronchiectasis
Childhood Interstitial Lung Disease	Chronic Obstructive Pulmonary Disease (Emphysema)	Idiopathic Pulmonary Fibrosis
Interstitial Lung Disease	Lung Cancer	Nontuberculous mycobacteria (NTM)
Occupational Lung Disease	Paediatric Lung Disease	Pulmonary Arterial Hypertension
Pulmonary Fibrosis	Pulmonary Hypertension	Sarcoidosis
Tracheobronchomalacia (TBM)	Other	Disease type: Other

Thank you for indicating you have been diagnosed with an Occupational Lung Disease. To better understand your diagnosis, can you please specify your condition(s) below:

Asbestosis	Coal Worker's Pneumoconiosis	Hypersensitivity Pneumonitis	Mesothelioma
Pneumoconiosis	Silicosis	Work-related Asthma

Have you had any of the following Respiratory Infections?  Please select all that apply

COVID-19

Pneumonia

Influenza

Tuberculosis

We offer a wide range of resources, information and courses for our Health Professionals. What area are you a Health Professional in?

Allied Health- Exercise	Allied Health- Other	Allied Health- Pharmacy
Aboriginal and Torres Straight Islander Health Worker	Doctor – GP	Doctor- Specialist
Nurse	Other	Health Professional/Nurse Type: Other

What are your areas of interest?

Aboriginal and Torres Straight Islander Communities	Bronchiectasis	COPD
COVID - 19	Exercise	Idiopathic Pulmonary Fibrosis
Lung/Thoracic Cancer	Occupational Lung Disease	Paediatric Lung Disease
Palliative Care	Pulmonary Arterial Hypertension	Pulmonary Fibrosis
Pulmonary Hypertension	Rare Lung Disease	Research
Respiratory and sleep	Other	Special Interest Area: Other

Due to limited supply of the COPD-X Handbook, we encourage individuals to consider sharing hard copies with their colleagues. Please select your request below

I would like to register on behalf of my organisation I would like to register as an individual 

Organisation details

Organisation Name:

Number of copies requested:

Maximum of 5 copies only.

Please provide Shipping details below:

Shipping Contact Details

Salutation

Please select... Assoc Prof Dr. Master Miss Mrs. Ms. Prof. Senator The Hon Dame Sir

First Name 

Last Name

Email

Mobile

Shipping Address

Street Address

Suburb

State

Please select... NSW VIC ACT NT WA QLD SA TAS

Postcode

Country

Please select... Australia New Zealand Other

By clicking submit I understand that I may be contacted as set out in the Privacy Statement.