Healthcare Professional Registration

Thank you for your interest in Doc Abode

This registration form is for Healthcare Professionals (HCPs) to submit the necessary information for verification in order to work on cases managed and assigned through the Doc Abode platform.

Email Address *

Confirm Email

Password

Please ensure your password contains a minimum of 8 characters including one capital letter, one number and one non-alphanumeric character

Personal Details

Forename *

Surname *

Date of Birth *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Mobile Phone Number *

Device which will have the Doc Abode app installed *

National Insurance Number *

Emergency contact details *

Please include your emergency contact's Name, Relationship to you, Address, Daytime phone number and Evening phone number.

Finance Details

Bank Name *

Account Name *

Sort Code *

Please enter numbers only, no dashes

Account Number *

Bank Address *

Are you engaging with Doc Abode or the healthcare provider as: *

Are you currently a member of the NHS pension scheme?

What is your pension SD number? *

You can find your SD number on any correspondence sent to you from NHS pensions, on some payslips and your online Total Reward Statement; it's an eight digit figure and starts SD. If you can't find your SD number, you can call the NHS pensions helpline on 0300 330 1346.

What is your NHS pension scheme tier % deduction?

Please enter numbers only (%)

Equality and Diversity

This information is collected for equality and diversity monitoring only under the terms of the terms of the Equality Act 2010 and in line with NHS England and NHS Digital best practice and is not compulsory.

Gender

Marital Status

Ethnic Origin

Country of Birth

Nationality

Disability

Religious Beliefs

Sexual Orientation

Doc Abode Preferences

In some cases, Doc Abode can match a clinical case type (where identified) with a healthcare professional (HCP) according to their interests / experience / qualifications. In order to correctly match each case (telephone / video / face to face), please inform us of any clinical areas which you have an interest, further experience, expertise or qualification in. Conversely, a HCP can identify specialisms they would rather not accept as a case. If you would rather NOT be notified of certain clinical cases, please mark these under the 'do not inform' column (please note, these may still appear in your 'Available Jobs' list within the app, which you can choose to ignore).

Please identify all specialities that you have expertise, interest, experience or qualifications in (please select all that apply)

Cardiology
Dermatology
Diabetes
Elderly
ENT
Gastroenterology
Mental health
MSK
Neurology
Ophthalmology
Paediatrics
Palliative
Respiratory
Section 12(2) approved doctor (MHA)
Urology
Woman's health/O&G

If other, please specify

Please identify all specialities that you DO NOT want to be notified about

Cardiology
Dermatology
Diabetes
Elderly
ENT
Gastroenterology
Mental health
MSK
Neurology
Ophthalmology
Paediatrics
Palliative
Respiratory
Section 12(2) approved doctor (MHA)
Urology
Woman's health/O&G

If other, please specify

Please identify the languages that you would be comfortable in consulting in during a case (please select all that apply)

Arabic
Bengali
Cantonese
French
German
Gujarati
Italian
Lithuanian
Mandarin
Other Chinese
Polish
Portuguese
Punjabi
Somali
Spanish
Tamil
Turkish
Urdu
Welsh

Professional Details

Professional Status *

What is your primary GP function? *

GMC Registration Number *

Professional Body ID (if applicable)

e.g. NMC number, GPhC number

Date of Full GMC Registration

Practice Name (if applicable)

This will be used to notify you of Doc Abode home visit matches to patients registered under your practice.

Practice Code

This will be used to notify you of Doc Abode home visit matches to patients registered under your practice. Please enter 'Unknown' if you are unsure of your practice code.

Practice Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Practice Telephone Number

NHS Smartcard Number *

Professional Qualifications *

Please confirm: *

I am currently registered with the General Medical Council
I am not aware of any complaints against me that have been referred to independent review by NHSE or the GMC
I have no restrictions on practice or changes in GMC registration status
I am currently included on the NHS England Performers List
I have not been suspended from the NHS England Performers List
I accept the professional obligations placed on me in Good Medical Practice paragraphs 28-30 (GMC 2013) about my personal health

Please state your Medical Indemnity Organisation: *

MDU, MPS, MDDUS or Other (please specify)

Number of weekly sessions that can be worked in OOH

Please ensure you have the necessary OOH indemnity 'allowance' cover to undertake any Doc Abode home visits

Employment History *

For each position, please include Employer, Position Held and Dates of Employment (from - to)

General

Do you possess a current driving licence? *

Do you hold valid business insurance for your car? *

Have you ever been convicted of an offence (including motoring but not parking offences) or are any charges or summons at present outstanding against you? *

If yes, please give details:

Note

By virtue of the Rehabilitation of Offender's Act 1974, Section 4(2) of the Rehabilitation of Offender's Act 1974 does not apply to this question. You are therefore not entitled to withhold information about a previous conviction on the grounds that it is for other purposes spent under the Act.

References

Please note that at least one reference should be your current or most recent employer and must be in clinical practice.

Reference 1 Full Name *

Reference 1 Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Reference 1 Telephone Number *

Reference 1 Email Address *

Confirm Email

Reference 2 Full Name *

Reference 2 Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Reference 2 Telephone Number *

Reference 2 Email Address *

Confirm Email

Supporting Documentation

Proof of Right to Work *

Please upload a copy of your passport or other recognised photo ID. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

(Advanced) DBS Certification *

Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Proof of Indemnity *

Where national scheme is not applicable. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Vaccination & Test Records

All staff should be up to date with their routine immunisations e.g. tetanus, diptheria, polio and MMR. Satisfactory evidence of protection would include documentation of having received two doses of MMR or having had positive antibody tests for measles and rubella. Evidence of antibody titres for hepatitis B is also required. Tuberculosis BCG vaccination is also recommended for healthcare workers.

Please select which routine immunisations you have received: *

MMR
Hepatitis B
Tuberculosis

Please upload evidence of your vaccinations if available

Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Latest Covid-19 status *

Training and Development

Please upload certification for each of the following items if available. The healthcare provider's HR team may be in touch if there are any omissions which may affect your registration.

Please select which training you have undertaken and have the appropriate certification for: *

BLS Resuscitation
Data Security Awareness
Infection Control
Safeguarding Adults Level 1
Safeguarding Adults Level 2
Safeguarding Adults Level 3
Safeguarding Children Level 1
Safeguarding Children Level 2
Safeguarding Children Level 3
Safeguarding Children Level 4
P.R.E.V.E.N.T
Moving and Handling
Health and Safety
Fire Safety
Conflict Resolution

BLS Resuscitation

Please upload BLS certification, if available. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Data Security Awareness

Please upload any evidence or certification to demonstrate Data Security Awareness, if available. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Infection Control

Please upload any evidence or certification to demonstrate infection control and prevention adherence, if available. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Safeguarding Adults

Please upload evidence of your highest level of Safeguarding Adults certification, if available. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Safeguarding Children

Please upload evidence of your highest level of Safeguarding Adults certification, if available. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

P.R.E.V.E.N.T

Please upload evidence of your P.R.E.V.E.N.T certification. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Moving and Handling

Please upload evidence or certification of Moving and Handling training. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Health and Safety

Please upload evidence or certification of Health and Safety training. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Fire Safety

Please upload evidence or certification of Fire Safety training. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Conflict Resolution

Please upload evidence or certification of Conflict Resolution training. Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

Please confirm which systems you are proficient with: *

ADASTRA
TPP SystmOne
EMISWeb
None
Other

Systems GP proficient with ADASTRA, TPP SystmOne, EMISWeb, (or equivalent)

Maximum file size 5MB. File types accepted include .pdf .jpg .png .doc .docx

If other, please specify

Declaration

I confirm that: *

The information I have provided is correct and understand that misleading statements may be sufficient grounds for cancelling any agreements made
Questions left unanswered or partially answered may be discussed arising from this application
I am happy to receive marketing emails from Doc Abode

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