1. Full name.
2. Sex.
3. Date of Birth.
4. Private address and telephone number.
5. Medical qualifications and where obtained.
6. Registration number in the Medical Register and date of first registration.
7. Information about general medical services to be provided for persons in the FHSA’s locality, and in particular whether—
(a)including excluding limited to | maternity medical services |
(b)including excluding limited to | contraceptive services |
(i)excluding including | fitting of intra-uterine devices |
(ii)restricted not restricted | to patients to whom the doctor or partner provides other personal medical services |
(c)including excluding limited to | child health surveillance services |
(d)including excluding limited to | minor surgery services |
8. Present or most recent appointment.
9.—(a) Name and private address of any intended partner and whether or not the name is in the FHSA’s medical list.
(b)Names and private addresses of members of group (other than those already specified in (a) above) with whom doctor intends to practise.
10. Whether applied/intending to apply for inclusion in obstetric list/child health surveillance list/minor surgery list.
11. Notification of the geographical boundary of the applicant’s proposed practice area by reference to a sketch, diagram or plan.
12. Notification of address(es) of proposed practice premises.
13. Whether the applicant intends to practise as—
(a)a full-time doctor;
(b)a three-quarter-time doctor;
(c)a half-time doctor;
(d)a job-sharing doctor; or
(e)a restricted doctor.
14. Where the applicant intends to practise as a job-sharing doctor, the name of the other job-sharing doctor with whose hours the applicant’s hours are to be aggregated for the purposes of regulation 15(1)(d).
15. Notification of proposed days and hours of attendance.
16. Telephone number(s) at which prepared to receive messages.
17. Undertaking that if accepting as a patient a person who, at the time of acceptance, is residing at a place outside the practice area, he will visit him at that address.
18. Proposed place of residence (including telephone number and distance from main practice premises) and an undertaking to inform the FHSA whenever changing permanent residence.
19. Declaration that he is a registered medical practitioner, included in the Medical Register in that name.
20. Undertaking to be bound by the terms of service.