Athena Surgical Centre: Practising Privileges Application

Practising Privileges

(Application Form)
Personal Details:

The company is an equal opportunities employer. We are committed to ensuring within the framework of the law that our workplace is free from unlawful or unfair discrimination on the grounds of colour, race, nationality,ethnic or national origin, sex, gender (including gender reassignment), sexual orientation, age, marital status or disability. We aim to ensure that all our staff, external contractors and independent practitioners achieves their full potential and that all employment decisions are taken without reference to irrelevant or discriminatory criteria.
Name:*

PrefixFirst NameLast Name
Preferred Name:
Date of Birth:*

DayMonthYear
Date
Gender:*
Marital Status:
Specify "Other" marital status.
Ethnicity:*
Specify "Other" ethnicity.
(Ethnic origin questions are not about nationality, place of birth or citizenship. They are about colour and broad ethnic groups. UK citizens can belong to any of the groups indicated above.)
Nationality:*
Please provide a copy of your Passport. *

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Do you Need a work permit ?*

YesNo
Please provide proof of "Right to work in the UK".*

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Do you have a disability?*

YesNo
Please provide further details.
Job Title:*
(Position Applied for)
Speciality *
Do you have BLS/ALS certificate ?

YesNo
Please Attach BLS / ALS certificate.

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Please Attach ALS certificate.

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Please Attach ALS/ILS/BLS certificate.

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Principal Qualification(s):*
(Please enclose a copy of your current CV)
Attach Your Current CV here. *

Only (.pdf, .doc or .docx) attachment is allowed.
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Do you have employment Gap(s) ?

YesNo
Commentary of gap(s) in employment:
Email ID: *
Professional Title:
(For mailing Purposes)

Mobile Number (Work)*
Please enter a valid phone number.
Mobile Number (Work)*
For out-of-hours if different from above
Local/Home Details:
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Please include two proofs to address.*

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Mobile Number (Home)
Please enter a valid phone number.
Travel-Time to the Surgical Centre (In Mins) from home. *
What arrangements have you made to provide consultant cover for your patients in your absence?
Consultant Cover: Contact Person Details
Person Name : First Name*   Last Name*
Mobile Number :   0447712345678*
Email ID: Email*
Work Contact Details:
Address Type:
Address:

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Travel-Time to the Surgical Centre (In Mins) from above address.
Email ID:
Mobile Number:
Please enter a valid mobile number.
Tick category of Practicing Privileges for which you are applying.*

Consultation in the out-patient’s department (including medico-legal work).Consultation and minor procedures in the out-patient’s department.Consultation and minor procedures in the out-patient department plus admission of in/day patients.Consultation and minor procedures in the out-patient’s department plus admission and operative procedures on in/day patients.Admission and care of in/day patients onlyProvision of anaesthetic services.Diagnosis and therapeutic imaging procedures and reporting and provision of advice to colleagues including admission and interventional procedures.Diagnosis and therapeutic imaging procedures, reporting and results and provision of advice to colleagues.Administration of sedation by Consultants other than Anaesthetists.

Please give names of any other private hospitals where you have applied for or been granted/ refused practicing privileges.*

GrantedRefused
Granted practicing Privileges:
Refused practicing Privileges:
Please give details description of the scope of your normal practice, listing those procedures you intend to undertake within the scope at Athena Surgical Centre:*
Attach any file if you want to attach.
File Upload:

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Areas of sub- specialities (Within your scope of practice, please provide further details of any sub-specialities, or additional training that you have received– e.g. Laparoscopic techniques).
(Please provide details training and certificates, and date of issue as part of application)
File Upload:

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Appraisal and Revalidation
When is the annual appraisal due?*

DayMonthYear
Date
Please upload a copy of annual appraisal.*

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When is your revalidation due ?*

DayMonthYear
Date
Please upload a copy of your revalidation.*

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Registration Details
Are you registered with the GMC/GDC?*

YesNo
Certificate Reference:
Please attach a copy of your certificate:

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Please list any other professional organisations with which you are registered:
Are you registered with a medical defence organisation?*

YesNo
Certificate reference:
Please attach a copy of your certificate:

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Please give your Data Controller registration number.
Disclosure and Barring Service / Criminal Records Office (Scotland)
Have you ever undergone a disclosure?*

YesNo
Please state when this took place, by whom it was requested and for what purpose:
Was the DBS/ CRO disclosure enhanced or standard?
Attach a copy of currently active enhanced DBS certificate: *

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Valid Till date of DBS*

MonthDayYear
Date
Note :

If you require Enhanced DBS, we will organise it for you. The applicant will need to bear the applicable fees.
Other Interests
Do you have any direct managerial or financial interest in any other Private Health Care organisation or Hospital or Clinic?

YesNo
(N.B. A share holding in any publicly quoted company undertaking healthcare activities will not be deemed to be a direct financial interest for the purposes of this question)
Please give details of managerial or financial interest in other Private health Care organisations.
Attachment for managerial or financial interest (If any).

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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Practising Privileges

Personal Details:

Local/Home Details:

Work Contact Details:

Consultancy Details:

Appraisal and Revalidation

Registration Details

Disclosure and Barring Service / Criminal Records Office (Scotland)

Other Interests

Referees:

Declarations

Indemnity Details:

Specifications by the Consultant for Practicing Privileges: