Confidential Practice Information

Practice Name*

Surgery 1 address

Surgery 2 address

Postal Address

Surgery 1 Telephone

Surgery 2 Telephone

Fax

Email*

Practice Manager

Please list ALL Doctors associated with Practice

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Code 1 Contact GP re all hospitalisations?

Please Select Yes No

Code 2 Contact GP if patient is critical?

Please Select Yes No

Code 3 Contact GP re deaths immediately?

Please Select Yes No

Code 4 Refer all patients to GP next surgery session?

Please Select Yes No

Code 5 Contact GP re obstetrical problems?

Please Select Yes No

Code 6 Locum to contact operator prior to any hospital admission? (See code 1)

Please Select Yes No

Code 7 Bulk Bill all patients?

Please Select Yes No

Code 8 Locum to advise operator if long delays likely? (See code 9)

Please Select Yes No

Code 9 Operator to contact Practice duty doctor if long delays are likely?

Please Select Yes No

Code 10 No narcotic to be administered?

Please Select Yes No

Special Instructions (Please list any Practice-specific instructions)

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GP Instructions (Please list any Doctor-specific instructions)

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Please attach list if insufficient space:

Upload Patient Instructions

Does the Practice bulk bill? (Please answer most applicable)

All patients? Please Select Yes No

Health Care & Pension Card Holders? Please Select Yes No

Nobody? Please Select Yes No

(Please complete if you provide us with a duty doctor)

Duty Doctor

How will you advise us if duty doctored rostered?

When should we contact the duty doctor?

Any special instructions?

Public

Private

Is the practice in the PIP?

Prescribing program you use?

Accounting program you use?

Call Diversion (This requires automatic diversion of clinic phone after hours)

Do you want us to answer the phone in the Practice name? Please Select Yes No

Comments

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