» GPwSI Directory Submission Form

GPwSI registration form

Please complete this form to allow us add your details to the GPHQ Directory as a GP with a Special Interest.

Name*
Your name including salutation e.g Dr
Best contact email address
This is for our use only and WILL NOT be displayed on the directory or shared with anyone else.
Special Interest(s)*
If more than one please list all special interests below. e.g Skin Cancer Surgery, Cosmetics.
Practice Name*
Practice street address including postcode*
Practice Phone number*
Practice Fax Number*
Email address (optional)
The email address referring GPs can best contact you at. Will be displayed in the directory.
Website (optional)
Special Interest Information/Description/Bio (for display in your listing)
Please include: -Details of your interest and experience/additional qualifications. -Important info for GP referrers E.g. for Mirena insertion is a consultation required first with insertion on a diffferant day? For skin lesion excision is a consult required before the excision? -How you would like to receive referrals- e.g. just book in, phone you, write to you...etc. -Your Fees. ?Gap, Bulk Bill, medicare rebate? Discounts for Pensioners? -What information would you like the GP referrer to send you in the referral? What tests would be useful for that GP to perform in advance eg; histology results/ pre-mirena swabs?. Should the patient bring copies of investigation results? -Anything you DO NOT DO? Write it here to reduce inappropriate referrals?
Headshot (optional)
A photo of you. If you have difficulties uploading, please email as an attachment to admin@gphq.com.au
Max. file size: 512 MB.
Clinic/Practice Logo (optional)
If you have difficulties uploading, please email as an attachment to admin@gphq.com.au
Max. file size: 100 MB.
Patient Information Leaflet / Referral Template (optional)
Drop files here or

Accepted file types: pdf, Max. file size: 100 MB.