After hours doctors house calls in South East Queensland and North and West Sydney.

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HOME >> SUBSCRIBER INFORMATION >> APPLICATION FORM

APPLICATION FORM


(All information provided by you is confidential.
Details will not be disclosed to anyone except at your request).


Principal General Practitioner:
Practice name: *
Practice location:
Postal address:
Post code:
Main surgery phone number:
Email: *
Mobile / pager number:
Fax number:
Second surgery phone number:
Home number:
Please click if your Practice would not like to join the Family Care Friendly Society: 

Name of Practice Manager:       

SURGERY HOURS (time from when phone is answered):

Mon:   from to
Tue:   from to
Wed:   from to
Thu:   from to
 
Fri:   from to
Sat:   from to
Sun:   from to
Public Holidays:   from to
Do you use a call diversion facility on your telephone after-hours?

Yes   No
Do you use recorded message equipment on your telephone after hours?

Yes   No
SPECIAL INSTRUCTIONS (Please mark)
Please forward a copy of all pathology results.

Yes   No
Please fax patient reports daily.

Yes   No
Please post patient reports.

Yes   No
Please call me before any urgent referrals to hospital.

Yes   No
Please notify me of all deaths.

Yes   No
Other

GEOGRAPHICAL BOUNDARIES:
I am aware of the current geographic boundaries of the after hours service and accept responsibility for making alternative arrangements for patients beyond those boundaries. If any of these patients contact Family Care Medical Services, following and/or communicate the following instructions:
 I agree to pay $per full-time equivalent GP (plus GST).
 I understand that subscriptions are subject to annual adjustments in accordance with the CPI.
Date:        Day:Month:Year:

Please advise Family Care Medical Services as soon as possible of any changes to your instructions, General Practitioner or telephone numbers. We welcome your suggestions to help us further improve this service.


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