Doctors’ Health Advisory Service Western Australia Doctors for Doctors listName Practice Address Street Address City State / Province / Region ZIP / Postal Code Practice contact numberSpeciality including GP QualificationsYear medical degree attainedGender Male Female Other Language spoken Telehealth: Do you do Telehealth consultations? Yes No Special interest areasBilling policy for doctors and medical students Bulk bill all Private bill all Discount private Bulk bill 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.CAPTCHA
