Medical Director Approval form
Name of Proposed Mentor:
*
First Name
Last Name
Trust
Post
Please Select
Consultant Urogynaecologist/Urologist
other (please specify)
Other (please specify)
Medical / Clinical Director :
Name
*
First Name
Last Name
Position
Department
Address
Street Address
Street Address Line 2
City
County
Postal Code
Email
*
example@example.com
Statement by Medical Director / Clinical Director:
I can confirm that -
Dr Name
Is employed by the trust -
Trust Name
compliant with our NHS high vigilance requirements
inputs their surgical data onto the required national databases (BSUG, BAUS, National Registries)
I approve them becoming a mentor, as part of the BSUG Surgical Mentorship Scheme, for the following procedure(s):
Open Colposuspension
Laparoscopic Colposuspension
Autologous Fascial Sling
Open Sacrocolpopexy
Laparoscopic Sacrocolpopexy
I can confirm that the Dr has been performing these procedures as part of their routine clinical practice for at least three years
Dr Name
Signed
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Submit
Should be Empty: