Expression of interest form

Doctors’ Health Advisory Service Western Australia Doctors for Doctors list
Name
Practice Address
Street Address City State / Province / Region ZIP / Postal Code
Practice contact number
Specialty including GP
Qualifications
Year medical degree attained
Gender
- Male
- Female
- Other
Language spoken
Special interest areas
Billing policy for doctors and medical students
- Bulk bill all
- Private bill all
- Discount private
- Bulk bill medical students
Email (for office use only)
I would be willing and able to use a code word system (“DHASWA Referral”) in my practice to identify and expedite doctor-patient referrals and appointments made via the DHASWA Doctors for Doctors list (optional).
I hereby give consent for the details provided in the form above to be included in the Doctors’ Health Advisory Service Western Australia (DHASWA) Doctors for Doctors list, and used in accordance with the purposes of the list, including being made available to DHASWA staff, who may refer callers to the DHASWA call line to you, and being made publically available on the DHASWA website.
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