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 addressThis 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 email@example.comMax. file size: 512 MB.Clinic/Practice Logo (optional)If you have difficulties uploading, please email as an attachment to firstname.lastname@example.orgMax. file size: 15 MB.Patient Information Leaflet / Referral Template (optional) Drop files here or Select files Accepted file types: pdf, Max. file size: 15 MB.