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Member of the Akessa Healthcare Group of hospitals

Practicing Privileges

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About You

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How Can We Reach You?

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Please upload a copy of your passport

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Date of your last validation

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Date of your last Appraisal – Please upload a copy

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Upload a copy of your Enhanced DBS Certificate

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Upload a copy of your CMA letter template

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Upload a copy of your CV in Word

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Upload a copy of your employee reference 1

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Upload a copy of your employee reference 2

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Please upload your biography for insertion on our website

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Please upload your photograph for insertion on our website

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Upload your copy of Hepatitis B antibody vaccination

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Upload your copy of any other vaccination(s)

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Upload a copy of Indemnity Insurance

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Check the box(es) of the Insurance companies you are registered with:

Check Box(es) if your registered

Details of your personal secretary, if applicable. To include, name, telephone number and email

Name

Can we share details of your personal secretary with your patients?

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Outline of services and list the procedures to be provided and how do you intend to bring your patients to our hospital(s) and contribute to the clinical practice of the organisation

Days and times you are available to work at our hospital

Do you require any administration / secretarial support from our hospital? If so, there will be a charge for this service.

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Please clarify if you charge the patients directly all the fees or you would like us to charge the patients and reimburse your fees?

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Do you create and bring your own patient medical records, or you prefer us to have these prepared for your clinic?

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Clinic room requirements – do you require any specific piece of medical equipment, medication or consumables to be made available in your clinic room?

If you carry out any surgery, do you require any specific instruments or medical equipment? We do encourage you to visit our theatres, to ensure that you are familiar with all the kit.

Has any member of your company / organisation, yourself, member of its board and/or senior management team ever been subject to legal business proceedings (administrative, medical or financial) including bankruptcy, practice restrictions or convictions? if applicable, please give full details or enter No. *

Are you a Controlled Drugs prescriber? If so, please insert your PIN number. If not a Controlled Drugs prescriber please enter N/A below

Speak to our team today

Get in touch to book an appointment, for further information, or to ask any question you wish. All contact is handled securely and confidentially.

Call us on

01295 252281

Message us on WhatsApp

+44 7470 996402