Request an appointment

Date *

I am filling the form on behalf of *

GP / Medical PractitionerMyselfSomeone else

First Name *

Last Name *

DOB *Date of birth

Phone Number *

Email Address

Reason for appointment *What is the reason for you to seek the appointment ? (this will help us respond better)

Preferred location for the appointment ? *

Either of the followingGawler (Gawler Surgical Specialists 16 Adelaide Road Gawler South SA 5118)Oakden (Oakden Medical Centre 132-134 Fosters Road Hillcrest SA 5086)

Please choose a preferred location. Wait times at different locations may differ.

Do you have private insurance with HOSPITAL cover ? *

YesNoNot sure

Please choose "No" if you have "extras only" medical insurance

Name of your insurance firmPlease provide details of your health insurance membership

Membership NumberPlease provide details of your health insurance membership

Do you have referral ? *

YesNo

If you have a copy of the referral, please upload it here. It will help us repsond better to your request (a clear copy please)

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Single file only. Max file size 5MB. Allowed file types pdf, jpg, jpeg

We can offer you an appointment without referral but you will need to bring a SIGNED referral to your appointment to be eligible for any Medicare Rebate.

Please ensure that the referral is signed by your medical practitioner to be valid. If you can't upload it, please fax it to (08 8523 2400), or bring it with you for the appointment

Referral from GP / Medical Practitioner

Browse

Single file only. Max file size 5MB. Allowed file types pdf, jpg, jpeg, txt, doc, dox

You can either upload a signed referral here or give it to the patient to bring it with them.

Please provide patient's contact details in the message box below if a referral is not uploaded.

Message or Comment

Please use this box if you need to advise us of any reasons for urgency, preferred location for appointment, patient contact details (if not on the uploaded referral), etc.

I have read and agree to Privacy Statement and Terms *

My name & relation to patient *Please provide your full name and relation if you are completing the form for someone else

Important Notice

Thank you for taking time to fill out a request for appointment form. We use the information provided on the form to create a file for the client and to help triage the urgency for appointment (if a referral is attached).

We will be in touch soon to book an appointment. We appreciate that you may be busy (or not have your calendar handy when we contact you). If you find it easier, w e invite you to contact us to schedule an appointment at your convenience on 08 8523 2500.

There is a lead time to the appointment. If you believe that your care needs are urgent, please ask your referring doctor to request it on the referral with the clinical reasons for the urgency and send the referral to us (email / fax / HealthLink) . We will not be able to prioritize the appointment request without this information.

Business hours: Monday to Thursday 08:30am to 04:30pm

Friday 08:30am to 01:00pm

(CLOSED weekends and public holidays)

(Phone): 08 8523 2500 (Fax): 08 8523 2400

(Email): reception@gawlersurgicalspecialists.com.au

(Website): www.gawlersurgicalspecialists.com.au

Signature *

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By completing and submiting the form, I confirm all responses are true to the best of my knowledge. I have read & accept terms and conditions.

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