Do you supply any after-hours services on weekdays in the period between Sydney Medical Service 1300HOMEGP ceasing to provide services (8.00am) and the opening time of your surgery?

 Yes No

Is your surgery an accredited practice?

 Yes No

Which Primary Health Network does the surgery fall under?

How would you like to receive your patient reports?

Do you wish to be notified immediately of urgent pathology results or any deaths during the afterhours period?

 Yes No

In accordance with its Rules, notice is given to the Applicant for Membership that the following documents are available for inspection at Sydney Medical Service’s office at 68 Anderson Avenue, Panania:

• A consolidated copy of its Rules

• Notice of the Subscription fees payable by Members

• Copies of relevant special resolutions passed by the Members, except resolutions providing for an alteration of the Rules

• A copy of the last Annual Report

Sydney Medical Service is currently offering registration to all surgeries based on a ZERO fees policy. Should fees ever be re-introduced, each surgery will be contacted prior to commencement of billing.

Sydney Medical Service 1300HOMEGP will distribute all notices to Members by email to the email address nominated on this Application for Membership.

Cancellation or resignation of membership must be in writing to Sydney Medical Service 1300HOMEGP and will take effect from the commencement of the following quarter.

The information supplied in this Application for Membership is complete and accurate. You agree to give notice in writing to Sydney Medical Service 1300HOMEGP of any changes to the information supplied in this Application for Membership as soon as is reasonably practicable.

If this Application for Membership is accepted, you (the named Applicant) will be admitted as a Member of Sydney Medical Service 1300HOMEGP. As a member, you (the named Applicant) will:

• be bound by the Rules of Sydney Medical Service 1300HOMEGP; and

• be entitled to the benefits of membership of Sydney Medical Service 1300HOMEGP (subject to the Rules of Sydney Medical Service 1300HOMEGP)

You are in practice alone at the surgery (or surgeries) nominated on this Application for Membership and will be the only Medical Practitioner entitled to receive the benefit of membership of Sydney Medical Service 1300HOMEGP under the Membership.

If any other Medical Practitioner commences practice from the surgery nominated on this Application for Membership, you will immediately notify Sydney Medical Service 1300HOMEGP of the details of such Medical Practitioner and agree to Sydney Medical Service 1300HOMEGP charging a revised subscription fee based upon the number of Medical Practitioners who shall receive the benefit of the services provided by Sydney Medical Service 1300HOMEGP. Should this occur:

• the original Applicant for Membership and any subsequent Medical Practitioners who commence practice from the surgery nominated on the Application for Membership shall be treated as Joint Members; and

• the original Applicant for Membership shall be regarded as the principal representative of the Joint Members.

You are aware of the boundaries and geographic regions presently covered by Sydney Medical Service and understand that:

• patients who reside outside of those boundaries will not be covered for after-hours care by Sydney Medical Service 1300HOMEGP; and

• it is your responsibility to make alternative after-hours arrangements for those patients.