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Practice Contact Details

Practice Name *

Surgery 1 Address *

Surgery 2 Address

Postal Address

Surgery 1 Telephone *

Surgery 2 Telephone

Fax

Email *

Practice Manager *


Doctors

Surname

Given Name

Full Time / Part Time No. of Sessions

Full Time / Part Time No. of Sessions

After Hours Emergency Tel. number


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Practice Instruction Codes

Code 1
Contact GP re all hospitalisations?

Code 2
Contact GP if patient is critical?

Code 3
Contact GP re deaths immediately?

Code 4
Refer all patients to GP next surgery session?

Code 5
Contact GP re obstetrical problems?

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

Code 7
Bulk Bill all patients?

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

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

Code 10
No narcotic to be administered?

Instructions

Special Instructions
(Please list any Practice-specific instructions)

Attach list if insufficient space:

GP Instructions
(Please list any Doctor-specific instructions)

Attach list if insufficient space:

Special Management Patients

Name / DOB

Address & Instructions


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Bulk Billing

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

All patients?

Health Care & Pension Card Holders?

Nobody?

Duty Doctor

(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?

Preferred Hospitals

Public

Private

Is the practice in the PIP?

Prescribing program you use?

Accounting program you use?

Other

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

Do you want us to answer the phone in the Practice name?

Comments

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