Step 1 Step 2 Step 3 Practice Contact Details Practice Name * Surgery 1 Address * Surgery 2 Address Postal Address Surgery 1 Telephone * Surgery 2 Telephone Fax Email * Practice Manager * Next Step Doctors Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Surname Given Name Full Time / Part Time No. of Sessions Full Time / Part Time No. of Sessions After Hours Emergency Tel. number Attach list if insufficient space: Click here to add more doctors Next Step Practice Instruction Codes Code 1Contact GP re all hospitalisations? Please SelectYesNo Code 2Contact GP if patient is critical? Please SelectYesNo Code 3Contact GP re deaths immediately? Please SelectYesNo Code 4Refer all patients to GP next surgery session? Please SelectYesNo Code 5Contact GP re obstetrical problems? Please SelectYesNo Code 6Locum to contact operator prior to any hospital admission? (See Code 1) Please SelectYesNo Code 7Bulk Bill all patients? Please SelectYesNo Code 8Locum to advise operator if long delays likely? (See Code 9) Please SelectYesNo Code 9Operator to contact Practice duty doctor if long delays are likely? Please SelectYesNo Code 10No narcotic to be administered? Please SelectYesNo 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 Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Name / DOB Address & Instructions Attach list if insufficient space: Click here to add more patients Bulk Billing Does the Practice bulk bill? (Please answer most applicable) All patients? Please SelectYesNo Health Care & Pension Card Holders? Please SelectYesNo Nobody? Please SelectYesNo 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? Please SelectYesNo Comments This form was completed by Your browser does not support JavaScript!. Please enable javascript in your browser in order to get form work properly.