Request an appointment

Date of form completion *

I am filling the form on behalf of *

MyselfSomeone else

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

Patient Details

First Name *

Last Name *

DOB *Date of birth

Age

You must be 18 years of age or above to be able to sign this form

Guardian Name *

Guardian's DOB *

Guardian's Medicare *

Contact Details

Address

Preferred Contact Number *Please provide the preferred contact number. We prefer mobile numbers to enable SMS notification of upcoming appointments.

Email AddressPlease consider carefully before providing official or work email address as we may communicate confidential or priviledged information to the email address provided

We send SMS reminders regarding appointments to your mobile. Do you consent to receive these? *

YesNo

SMS / Email communications include information related to appointments, results & follow up, recalls, letters to you or healthcare providers, etc.

Referral, Insurance & Concession Details

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

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

Browse

Single file only. Max file size 10MB. Allowed file types pdf, jpg, jpeg (a clear copy please)

We can offer you an appointment without a 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

Preferred location for the appointment ? *

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

Message or CommentWait times may differ depending on location choosen

Please use this box if you need to advise us of any thing that you consider important like reasons for urgency, interpreter needs, etc.

Wait times may differ depending on location choosen

Do you have Medicare ? *

YesNo

Medicare Number *Your Medicare number including reference number in front of your name

Do you have a concession card ? *

YesNo

Pension or Concession Card MUST be in your OWN name

Concession card number *Senior HCC Card is NOT accepted

Expiry Date for Concession Card *

Do you have private insurance with HOSPITAL cover ? *

YesNoNot sure

Please choose "Yes" ONLY if you have "Hospital Cover" on your insurance

Does your insurance provide HOSPITAL cover ? *

YesNoNot Sure

Please choose "No" if you have "Extras Only"

Insurance Fund *

Other Insurance *

Membership Number *Please provide details of your health insurance membership

Other Insurance Details *

DVAWorkCover / Third PartyOverseas Health Insurance / Visitor InsuranceNone of these

Other Insurance Membership Details *Please provide details of DVA or Overseas insurance as applicable

DVA Card Number *

DVA Card Type *

GoldWhite

Please select your DVA Card type

Does this card cover condition for which you are referred ? *

YesNoNot sure

Please note that only DVA Gold and approved DVA White cards are accepted

Case Manager Name *

Claim Number *

Claim Manager Contact Details *

Claim Manager Email Address *

NEXT OF KIN

Next of Kin Contact Name

Relationship *

Next of Kin Contact Number

Privacy Statement and terms

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 appreciate that you may be busy (or not have your calendar handy when we contact you). To make it easier for all of us, we 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 urgencyand 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

(CLOSED FRIDAYS, Weekends and Public Holidays)

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

(Email): reception@gawlersurgicalspecialists.com.au

(Website):www.gawlersurgicalspecialists.com.au

We are a private billing medical practice and all consults incur a fee. These must be settled on the day of consultation at the completion of your consultation. EFTPOS facilities are available for payment.

Most health care services provided by this practice are covered, at least in part, by Medicare and we send your paid account details to Medicare for reimbursement directly to you.

Gawler Surgical Specialists will collect information for the primary purpose of providing quality health care. We require details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs.

We may disclose this information to other healthcare providers (and their offices) directly or indirectly involved in your personal healthcare or medical treatment through fax, phone, email or other means of communication.

If you provide an email address, we will communicate with you using the email provided and you acknowledge your understanding of the security risks of email communication.

We will not disclose your personal information to ANY uninvolved third party unless required by law or directed by you

We require your consent to collect personal information about you and to use the information you provide in the following ways.

Administrative purposes in running our medical practice
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
Disclosure to others involved in your health care including locums attached to the practice,hospitals, treating doctors, and specialists outside this medical practice, through booking for procedures, referral to other doctors, or for medical tests and in the reports or results returned to us
Comply with any legislative or regulatory requirements e.g. notifiable diseases, credentialing activities
Communicate with you, including for reminder letters, which may be sent to you regarding your health care and management (e.g. results, recalls, follow up, etc.). These may be sent to you via SMS, email, post, fax or other electronic means to you or your GP / other involved health care providers
Research, teaching and quality assurance activities to improve individual and community health care and practice management. Information used does not identify you but should information that will identify you be required, you will be informed and given the opportunity to “opt out” of any involvement

I confirm that details provided above are correct to best of my knowledge. *

I have read the information above and understand the reasons why my information must be collected *

I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me. *

I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances. *

I understand that my further consent will be obtained BEFORE use of any of my information for any purpose other than set out above, and I can choose to withhold such consent *

I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice. *

This practice uses AI tools (currently Heidi) to transcribe the meeting and will be running in the background during the consultation sessions to record the details.
Please advise your doctor at the start of consultation if you do not consent to this. *

I have read and understood the privacy statement and terms as above. I am aware of my obligations and the obligations of the practice. *

Name

My name & relationship to patient *

Signature *

Draw signature|Type signatureClear

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

Save and Complete Later