Medic now | User Registration

Personal Details

Email*

Title*

First Name*

Last Name*

Have you ever been known by any other name?*

Have you changed your name through marriage/by deed poll, etc

Other Name*

If you have changed your first name or family name/last name, please provide all previous names above

Address 1*

Address 2

Town/City:*

Postal Code:*

Date of Birth (enter in format DD/MM/YYYY):*

National Insurance number?*

National Insurance Number must be entered in format AB123456C without any gaps

Gender*

Mobile number*

Valid mobile number would be: 07985123456

Nationality:*

Do you have EU Settlement Scheme status granting either Settlement or Pre-settlement status?*:

Do you hold a current full UK Driving Licence?:*

Emergency Contact

Emergency contact name:*

Relationship to you:*

Emergency contact number:*

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Your Speciality

Speciality:*

Click here to attach Your CV

Have you had an appraisal before?*

What was the date of your last appraisal?*

At which establishment was the appraisal completed?*

Please list any qualification(s) you hold*

If none, please enter N/A

NHS Employee

Are you permanently employed by the NHS in either a full time of part time capacity (excluding bank)?:*

If yes, is it full time or part time?

Are you registered with any NHS staff banks?:*

Professional History and References

Please provide details of all referees within the last 3 years. Please be aware that Medic Now is unable to offer you work until satisfactory references have been obtained, and that Medic Now is required to obtain references for you on an annual basis. We are required to obtain references to cover the last 3 years without gaps.  If provided here, this will speed up your clearance.
Important notes to consider when entering your referee details:
- Referees must have worked in a supervisory position to yourself.
- Referee emails entered must be business emails and not personal email accounts. Think @nhs.net rather than Gmail/Hotmail/Yahoo.
- Please note that the referees you have provided will be contacted once the compliance process has begun.

Referee 1

Organisation:*

Your Job Title:*

Ward/Dept:*

Grade/Band:*

Date Employed From:*

Date Employed To:*

Referee Name:*

Referee Job Title:*

Referee Email:*

Referee Telephone:*

Valid mobile number would be: 07985123456

Capacity Which Known:*

Referee 2

Organisation:*

Your Job Title:*

Ward/Dept:*

Grade/Band:*

Date Employed From:*

Date Employed To:*

Referee Name:*

Referee Job Title:*

Referee Email:*

Referee Telephone:*

Valid mobile number would be: 07985123456

Capacity Which Known:*

Referee 3

Organisation:

Your Job Title:

Ward/Dept:

Grade/Band:

Date Employed From:

Date Employed To:

Referee Name:

Referee Job Title:

Referee Email:

Referee Telephone:

Valid mobile number would be: 07985123456

Capacity Which Known:

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Medical Declaration/GP Details

CONFIDENTIAL - Due to the nature of the role you have applied for we need to carry out an assessment of a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by telephone from a clinician at Healthier Business UK Ltd, however you may also need to be seen by an occupational health advisor/specialist or physician, arrangements for face to face consultations will be arranged by your employer or agency. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.

GP Name:*

GP address line 1:*

GP address line 2:

GP address line 3:

GP Postcode:*

Medical History

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?:*

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?*

Do you think you may need any adjustments or assistance to help you to do the job?:*

Are you having, or waiting for treatment (including medication) or investigations at present?:*

Are there any reasons (medical or otherwise) why you would not be unable to carry out strenuous physical work including bending, lifting and carrying?:*

Do you have any eye or eyesight problems?:*

Do you have any hearing problems or difficulties?:*

Do you take any tablets or medication?:*

Have you ever had any of the following?

Diabetes*

Tuberculosis*

Angina*

Any other heart troubles*

Raised blood pressure*

Peptic, gastric or duodenal ulcer*

Indigestion for more than one week*

Back trouble, lumbago, sciatica, “slipped disc”?:*

Epilepsy, recurring blackout or fits?:*

Have you ever had any of the following during the past five years?

Bronchitis, asthma, pneumonia?:*

Dermatitis, eczema or other skin trouble?:*

Do you suffer from any of the following?

Migraine or severe recurring headaches?:*

Anxiety, depression or any other nervous complaint?:*

Fainting attacks or giddiness?:*

Ear trouble, discharging or infected ear?:*

Kidney trouble or urinary infection?:*

Have you ever had any operations requiring hospital admission for more than five days? :*

Have you ever been off work continuously for more than a month during the last 5 years?:*

Have you ever had to give up any previous job for medical reasons?:*

Do you have any other disability or serious illness?:*

Have you ever received compensation or a disability pension?:*

Have you consulted your doctor in the past 12 months regarding your health?:*

Have you suffered from any of the following?

Methicillin resistant staphylococcus aureus (MRSA)*

Clostridium Difficile (C-Diff)?*

Chicken Pox/Shingles

Have you ever had chicken pox or shingles?:*

BBV (Blood Borne Virus)

Have you ever come into contact with any BBV's (Blood Borne Virus)? Including Needle Stick Injuries?:*

Tuberculosis

Have you lived outside the UK or had an extended holiday outside the UK in the last year?*

Have you had a BCG vaccination in relation to Tuberculosis?*

Do you have a cough which has lasted for more than 3 weeks?*

Do you have unexplained weight loss?*

Do you have unexplained fever?*

Have you had tuberculosis (TB) or been in recent contact with open TB?*

Immunisation History

Have you had triple vaccination as a child (Diphtheria/Tetanus/Whooping Cough):*

Have you had a vaccination against polio?*

Have you had a vaccination against tetanus?:*

Have you had a vaccination against Hepatitis B?:*

Influenza

Have you received the vaccine for influenza in the past 12 months?:*

Exposure Prone Procedures

Will your role involve Exposure Prone Procedures:*

Medical Declaration - Consent

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing.
Further information regarding consent is available on the 'Candidate Screening Leaflet'. This is available upon request.

Do you consent to this questionnaire and your immunisation reports being assessed by an occupational health advisor for the purpose of providing a fitness to work certificate?

Do you consent to our occupational health advisers making recommendations to your employer/agency to assist with your ability to carry out your prospective role?:

Do you consent to our occupational health advisers speaking with you regarding any declaration you may have made relating to your medical history?: *

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return.
I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

The General Data Protection Regulation (GDPR) (EU) 2016/679

All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician, however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP, Specialist’s or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), withdrawal of consent and refusal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation.

Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/

If you wish to have sight of our privacy policy, please send your request to [email protected]

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Medic Now Registration

Personal Details

Emergency Contact

Your Speciality

NHS Employee

Professional History and References

Referee 1

Referee 2

Referee 3

Medical Declaration/GP Details

Medical History

Have you ever had any of the following?

Have you ever had any of the following during the past five years?

Do you suffer from any of the following?

Have you suffered from any of the following?

Chicken Pox/Shingles

BBV (Blood Borne Virus)

Tuberculosis

Immunisation History

Influenza

Exposure Prone Procedures

Medical Declaration - Consent

Declaration

The General Data Protection Regulation (GDPR) (EU) 2016/679

Declarations

Declarations of Criminal Convictions

Declaration of Confidentiality

Declarations – Working Time Regulations

Candidate Signature and Authorisation