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Medical Application Form
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Personal Details
Title
*
Example Mr, Mrs, Dr, Miss, Ms
Name
*
First
Last
Middle Names
*
Male
Female
Non-Binary
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Mobile Number
Home Number
Email
*
Date of Birth
National Insurance Number
Do You Hold a UK Driving Licence
Yes
No
Emergency Contact
Name
Relationship
Number
Email
*
Right to Work Details
Nationality
Do you require a Visa to work in the UK?
Yes
No
Visa type:
Professional Qualifications
Primary Qualification Held
Where was this qualification obtained?
Date of Qualification
Please list any other qualifications you have:
Professional Registration
Who is your professional registration held with?
Expiry Date
Do you have any other conditions to practice?
Yes
No
If you selected yes, please state your conditions?
Appraisal & Revalidation
Date / Time
Date / Time (copy)
Name of Appraiser
Location of Appraiser
When are you due to be revalidated? (If applicable):
Professional Referee Details
Please provide a minimum of two clinical, professional referees. One must be from your present or most recent employer and both must be a senior grade to yourself who have supervised your work. References must cover at least 3 years of clinical employment. By signing this application form, you confirm that you are happy for Agency to contact your referees unless otherwise stated.
Referee 1
*
First
Last
Referee Job Title
Place of Work
Ward
Contact Number
Professional Email Address
*
Employment Dates
Referee 2
*
First
Last
Referee Job Title
Place of Work
Ward
Contact Number
Professional Email Address
*
Employment Dates
Rehabilitation of Offenders / DBS Checking
Due to the nature of the work for which you are applying, you are exempt from the provision of section 4(2) of the Rehabilitation of Offenders Act 1974. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation to the positions in which the order applies. Failure to declare a conviction that later comes to light, may require us to exclude you from our register or terminate an assignment early.
Do you have any convictions, cautions, reprimands or final warnings?
Yes
No
At present, are you the subject of criminal charges or disciplinary action?
Yes
No
Are you currently subject to any investigation by an employer or professional body, or have you been in the past?
Yes
No
Have you had an enhanced DBS check (formerly CRB) within the last 12 months?
Yes
No
Is your DBS part of the annual, online update service?
Yes
No
Do you provide consent for Sirona Medical to regular check the status of your online DBS?
Yes
No
If your DBS certificate is part of the annual update service, you will need to provide us with a full, clear copy of your Certificate before we can complete the check online. If you do not have a DBS certificate that is part of the annual update service, then we will need to complete a new check through Sirona. The Compliance team can advise you on how to do this. We strongly advise that once you receive your new certificate that you join the DBS update service for an annual cost of £13. This will stop the need for a new disclosure being made every year. We will be happy to provide more information regarding the DBS update service should you require it.
Staff Handbook
Please click link to review and submit
Staff-Handbook
Once you've completed the Staff Handbook, please return to this page and tick to confirm. Upon registering with Sirona Medical you will have received a copy of our Staff Handbook which includes important information. You must read and familiarise yourself with the contents of our handbook, and in turn we will keep you updated with any changes.
Please Confirm
Tick to Confirm
I confirm that I have received, read and fully understood Sirona Medical staff Handbook and will adhere to its contents.
Working Time Regulations
The Working Time Regulations 1998 requires Agency to limit your average working week to 48 hours, unless you agree that this limit does not apply to you.
I do not agree to limit my working week to 48 hours maximum
I agree to limit my working week to 48 hours maximum
Please Sign & Date
Clear Signature
Date / Time
Date
Time
Professional Indemnity Cover
Who is your professional indemnity cover held with?:
Policy Number
Expiry Date
Declarations
By signing below, you are confirming the following declarations:
I am permitted to work in the UK, and should I have any restrictions on my right to work within the UK these have been declared within this form.
Confirmation
I understand that the information I have provided on this form will be used by Sirona Medical for registration purposes only and they will retain these details for as long as reasonably necessary in accordance with the Data Protection Act 1998.
Confirmation
I am not aware of any condition, medical or otherwise, which could affect my employment or limit my performance, other than those I have previously declared within my medical questionnaire.
Confirmation
I confirm that I have received, read and fully understood Agency Staff Handbook and will adhere to its contents.
Confirmation
I give my consent for Agency to carry out a DBS status check for the duration of my registration with them.
Confirmation
I am aware that certain compliance documents expire and it is my responsibility to ensure they are kept up- to-date.
Confirmation
I consent to my personal information being made available for the purpose of audits and any relevant third parties. This applies to all of the documentation I have provided to Agency including, but not limited to, my DBS, fitness to work certificate, reference checks, CV and right to work documents.
Confirmation
Full Print Name
*
Date / Time
Date
Time
Thank you for completing the Sirona Medical Candidate Application Form
Signature
Clear Signature
Submit
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