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Clinic Registration
Clinic Registration Form
Clinic Name
*
ABN Number
*
Clinic Address
*
Clinic Open Hours
*
Practice Manager Email
*
Accounts Email
*
Referral email
*
Respondent Name
*
1. Can the clinic conduct Spirometry testing?
*
Please select from one of the options
No spirometry available
Standard spirometry available
Qualified spirometry*
* Qualified spirometry relates to the training of the tester to the standards of the Thoracic Society of Australian & New Zealand. To meet these requirements, the tester must have completed the 1 to 1.5 day training course. In Victoria this can be undertaken at the Alfred Hospital, with the Asthma Council and some private trainers. This is distinct from short 2-3 hour courses.
Do you have staff members who have completed the necessary qualifications to conduct the Silica exposure Spirometry
*
Y / N
Yes
No
2. Can the clinic conduct Audiometry testing?
*
Please select from one of the options
No audiometry available
Audiometry available - NOT to Australian Standards
Australian Standards* audiometry - Audiometry Booth
Australian Standards* audiometry - Quiet Room
* To meet the Australian Standards the audio screen must be in a soundproof booth or a quiet room where an ambient noise assessment has verified the conditions as meeting the Australian Standards AS/NZS1269.4-2005.
3. Can the clinic conduct Instant urine drug screens?
*
Please select from one of the options
No instant urine drug screen available
Instant urine drug screen - NOT to Australian Standards
Instant urine drug screen - Australian Standards*
* Drug testing must be completed by an accredited collector as per the Australian Standard (AS/NZS4308:2008), this includes any non-negative results to be forwarded by Chain of Custody (COC) to an approved laboratory and that the test performed meets the standard.
Please advise which Pathology laboratory the clinic uses:
*
4. Can the clinic test for Alcohol via urine sample?
*
Y / N
Yes
No
5. Can the clinic test for Alcohol via breathalyser?
*
Please select from one of the options
No alcohol screen available
Alcohol screen via Breathalyser
Alcohol screen via Breathalyser - Australian Standards*
* Device is required to meet the Australian Standard AS3547-1997.
6. Can the clinic complete a lifting assessment?
*
Y / N
Yes
No
If yes, please tick the clinics lifting assessment capacity:
*
Please select from one of the options
15kg
20kg
25kg
The doctor is only required to observe correct lifting technique and ability. The clinic can use weights, or alternatively a box filled with A4 reams of paper or old books to the required weight
7. Do you have in-house Physiotherapy?
*
Y / N
Yes
No
4. If yes, please advise the clinic name
*
If no, Is there a co-located physiotherapy service?
*
Y / N
Yes
No
8. Can the clinic administer vaccines?
*
Y / N
Yes
No
If Yes, please advise which vaccines are kept in-stock by the clinic:
*
Hep B
Hep A
Hep A & B combined
Q-Fever Vaccine and Skin Test
Tetanus
Pertussis (Whooping Cough)
Varicella (Chicken Pox)
Do you hold any other vaccines in stock?
9. Would any of your medical practitioners or allied health staff (PT/Psych) be interested in the delivery of our initial care services.
*
Y / N
Yes
No
10. Would you be happy for MAX Health to contact you to discuss your responses?
*
Y / N
Yes
No
11. Have you completed and emailed us the signed copy of the EFT form?
*
Y / N
Yes
No
If you have not completed the EFT form, you can download it
HERE
.
Email
This field is for validation purposes and should be left unchanged.
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