Personal and Contact Information Name *
Mr. Mrs. Miss Ms. Dr. Prof. A/Prof.
Any former names including maiden name
Date of Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Mailing Address
Name of Partner/Spouse
(for Hospital invitation list)
Professional Practice Details Practice Name (1) Business Address (Primary Consulting Room)
Practice Name (2) Business Address (Other Consulting Rooms)
Professional Registration Details Please attach a copy of your Registration certificate
Category of Registration
Are there any conditions or undertakings currently attached to this registration? If yes, please give details
Have you ever been subject to an adverse finding or had conditions or undertakings attached to you registration by a medical board, dental board or other registration board (as appropriate)? If yes, please give details of the restriction and what period during which the restrictions apply/applied.
Professional Indemnity Please attach a copy of your professional indemnity certificate) Name
Indemnity Insurance Number
Category of Coverage
Does your membership fully cover the scope of clinical practice you have applied for? Has your medical defence insurer or any medical defence insurer or fund of which you have been a member ever applied conditions or refused to renew your cover or membership (in part or in full)? If yes, please provide details
Have there ever been any adverse findings made against you which would be relevant to your appointment (for example: breach of insurance/medical laws, professional misconduct, sexual assaults or assault) by the Health Insurance Commission, a Medical or Registration Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other negligence, professional, disciplinary or similar body? Criminal Record Check – Have you been convicted of, or pleaded guilty to a criminal offence including a serious sex or violence offence or an offence involving dishonesty or drugs (other than a spent conviction)? If yes, and if not prevented by confidentiality agreements, could you please provide a brief description of each adverse judgement or settlement, and the year in which the event occurred?
* This information is required to assess an application for scope of clinical practice and will only be used by Townsville Day Surgery for such purposes. Information provided will not be disclosed otherwise.
Please nominate a Medical Practitioner accredited at the Hospital in your Specialty available for contact by the Hospital in the case of an emergency if you are unavailable, and who has agreed to deputise for you.
Clinical Practice sought in the following category(s) Priveleges Sought Detail the scope of Clincal Practice Requested (Not applicable to Surgical Assistants) Anaesthesia Cardiac Surgery Dental Dermatology Emergency Medicine Endocrinology ENT Surgery General Surgery Gynaecology Medical Imaging Neurosurgery Nuclear Medicine Ophthalmology Oral & Maxillofacial Services Orthopaedics Palliative Care Physicians/Internal Medicine Plastic & Reconstructive Surgery Psychiatry Rehabilitation Medicine Thoracic Surgery Urology Vascular Surgery Other Clinical Practice Sought (Not applicable to Surgical Assistants) Referees For each major specialty in which you are seeking clinical practice, please provide names, addresses, telephone numbers, facsimile numbers and email addresses of three (3) professional referees (at least one from your own profession) who can attest to your recent practice and have known you for at least 12 months within the past 3 years. We prefer (where possible) that these referees are independent. However, where there is a relationship which may lead to a bias, such as a referee and the applicant are in business together as a partnership, or are employer/employee, then this relationship must be disclosed by you to the hospital. Please note that your referees will be contacted and asked to provide a reference. The reference should be in writing.
Specialty Referee 1 Name
Referee 2 Name
Referee 3 Name
Specialty Referee 1 Name
Referee Name 2
Referee Name 3
Professional Development over past 3 years - Please include any research activities, funded projects and quality assurance activity.(List below or attach CV) Current Public Hospital Appointments (List below or attach CV) Hospital and Appointment
Hospital and Appointment
Current Scope of Clinical Practice at other Private Hospitals (List below or attach CV) Hospital and Appointment
Have you previously been refused clinical privileges at another health care facility? If yes, please provide the name of the facility and rationale for refusal. Please note a senior executive of the Hospital may contact the facility.
Has your scope of clinical practice and/or appointment at any Hospital or Day Procedure Centre ever been reduced, suspended or revoked (including if done by mutual agreement) or have you had conditions attached to that appointment for any reason? If yes, please give dates and particulars. Please note a senior executive of the Hospital may contact the facility
Details of all Health Care related employment within the last 10 years (List below or attach CV) Hospital and Appointment
Special Professional Interests
Are you a member of any Specialist College(s)/Association(s)? (If yes, please provide details)
Publications (List below or attach CV)
Declaration and Authority
I authorise the Townsville Day Surgery, its employees, officers and the Medical Advisory Committee, to obtain information on an annual, or as necessary, basis from the registration body/indemnity insurance organisation as nominated in this application, regarding the currency of my registration/membership of that body/organisation.
I authorise the Townsville Day Surgery to include my practice details in any Hospital Specialist Directory.
I authorise Townsville Day Surgery to conduct a criminal record check in respect of my history including information relevant to the provision of services to children and I agree to notify the Chief Executive Officer if I am convicted of a sex or violence offence or any other offence relevant to my practice as a Medical Practitioner.
I authorise the Townsville Day Surgery, its officers and the Medical Advisory Committee to verify with relevant individuals, external organisations, and nominated referees the validity of all claims, including complaints made, including explicit consent for the organisation to verify my declaration regarding health status, professional registration history, claims and legal proceedings.
I declare that I have no physical or mental condition or substance abuse problem that could affect my ability to exercise the scope of clinical practice requested or that would require any special assistance in order to enable me to exercise that scope of clinical practice safely and competently. I undertake to notify the Townsville Day Surgery if this statement becomes incorrect in the future.
I declare that my medical indemnity/professional indemnity cover is adequate and appropriate for the Clinical Privileges and activity which is the subject of this application.
I declare that I am the person named in this application and that the information provided by me in this application and in connection with this application is accurate and complete and is not misleading or deceiving or likely to mislead or deceive. I understand that if I have provided misleading or deceptive information, or information which is likely to mislead or deceive, that the Townsville Day Surgery Board may (in its absolute discretion) consider that I do not have ‘current fitness’ under the Hospital By-Laws.
In applying for appointment I acknowledge that I have been provided with, and read, a copy of the Hospital By-Laws and if appointed, agree to abide by the By-Laws and policies of the Townsville Day Surgery, including any annexure or variation to the By-Laws during the tenure of my appointment, all relevant legislative requirements (including compliance with HQCC Standards) and any terms and conditions which are attached to my appointment by the Board/Licensee. I understand that non-compliance with the Hospital By-Laws may be grounds for suspension, termination or imposition of conditions on my clinical privileges.
I undertake to notify the Townsville Day Surgery promptly and in writing, if my scope of clinical practice is altered in any way at any other hospital or day procedure centre.
I agree to attend committee and clinical meetings at the facility to support my discipline within the facility, and to participate in any clinical quality assurance activity including submitting my practice to clinical audit and peer review, in conjunction with the hospital, the Medical Advisory Committee or clinical specialty committees if required by Townsville Day Surgery.
I undertake to notify Townsville Day Surgery should any information provided in this application for appointment vary in any way
I acknowledge and agree to release and indemnify Townsville Day Surgery from and against all claims, including legal costs, out of a decision to suspend or terminate my accreditation or to not re-appoint me in circumstances set out in the Hospital By-Laws.
In the event of myself or the aforementioned practitioner(s) being unavailable in the case of an emergency, I am agreeable to the facility seeking urgent alternative assistance with authority to be exercised only after consultation with the facility Chief Executive Officer or duly authorised person.
I understand that my Appointment will be reviewed in three (3) years or earlier if considered necessary.