Organisation / Practice Registration

Thank you for your interest in Doc Abode

This registration form is for organisations to submit the necessary information for verification in order to use the Doc Abode platform to assign cases to healthcare professionals.

Email Address *

Email

Confirm Email

Password

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

Organisation / Practice Details

Organisation / Practice Name *

Organisation / Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

ODS code *

If you are unsure of your organisation's ODS code, you can visit https://odsportal.hscic.gov.uk to retrieve it.

Lead Contact Name *

Lead Contact Email Address *

Lead Contact Phone Number *

Is the Lead Contact Patient-Facing?

If the lead contact is patient-facing, we will also require the contact details for a non-patient-facing person in the organisation / practice.

Organisation / Practice Finance Details

Bank Name *

Account Name *

Sort Code *

Please enter numbers only, no dashes

Account Number *

Bank Address *

Systems and Processes

Please Upload your Practice Handbook and Protocols *

Maximum file size 10MB. File types accepted include .pdf .jpg .png .doc .docx

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