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GP (General Practitioner) Registration

To register with S&T Medical Services- please fill out the form below and the appropriate member of staff will contact you at the earliest opportunity.

First Name*
Surname*
Gender		MaleFemale
D.O.B *
Nationality
Country of origin
Address *
Postcode
Telephone (Home)*
Telephone (Mobile)*
Telephone (Work)
Bleep
E-mail *
Fax
National Insurance Number
Available from
Name and Address of Present Employer
Telephone Number
GMC/GDC Registration *
Registration number
Type
Registration expiry
MDU/MPS/MIA Number *
JCPTGP Certificate Number *
Supplementary List Number
Health Authority
Computer systems you are familiar with
Other information
Immigration Status:
Do you hold a British passport?		Yes No
Do you hold a 'Student visa' ?		Yes No
Do you need a work permit to be able to work in UK?		Yes No
Where did you hear about us?		Please Select... Vision Campaign BMJ Careers Fair BMJ Advert Hospital Doctor GP Magazine Friend/Colleague Medical Staffing Yahoo Google Other Search Engine Other
Professional Referees:
Name
Position
Address
Postcode
Tel
Fax
Email
Name
Position
Address
Postcode
Tel
Fax
Email
Fitness to Practice:
Have you ever been the subject of Professional Misconduct Proceedings?		Yes No
Have you obtained CRB Clearance?		Yes No
I have read the Terms and Conditions *
The information you supply us is in strict confidence and will not be used for any other purpose in line with the 'Data Protection Act'

Note: To ensure registration is fully completed please ensure the following is returned to S&T Medical Services:

• A copy of your GMC Certificate
• Completed CRB Form
• Completed Registration Completion form
• A copy of your JCPTGP Certificate
• A copy of your letter of inclusion onto the Supplementary List
• Evidence of eligibility to work in the UK
• A Copy of passport for ID security purposes and NI number
• 2 passport size photographs for Identification Badges
• Confirmation of membership to MDU/MPS
• Download and confirm you have read the Terms and Conditions
• Evidence of Professional Indemnity Insurance
• Next of Kin
• Emergency contact telephone number

This information can be returned via:
Fax: 01784 422320
Email: info@stmedical.co.uk
Post: 157 Stanwell Road, Ashford, Middx, TW15 3QN