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Organisation / Practice Registration
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Step
1
of 4
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
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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?
Please select
Patient-facing
Non-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.
Contact 2 Name (non-patient-facing)
*
Contact 2 Email Address (non-patient-facing)
*
Contact 2 Phone Number (non-patient-facing)
*
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Organisation / Practice Finance Details
Bank Name
*
Account Name
*
Sort Code
*
Please enter numbers only, no dashes
Account Number
*
Bank Address
*
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Next
Systems and Processes
Please confirm which system(s) you operate with:
*
ADASTRA
TPP SystmOne
EMISWeb
None
Other
If other, please specify
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
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