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

Speciality including GP

Qualifications

Year medical degree attained

Gender

Male
Female
Other

Language spoken

Telehealth: Do you do Telehealth consultations?

Yes
No

Special interest areas

Billing policy for doctors and medical students

Email address (for us to contact you, office use only)

I am 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.
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 from the DHASWA call line to you, and being made publically available on the DHASWA website.

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