Regulation 16(c)
1. Full name.
2. Sex.
3. Date of birth.
4. Private address.
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 Board’s area, 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 GP or partners 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) Names and addresses of intended partner(s) and whether or not they are on the Board’s Medical List;
(b)Names and addresses of members of group (other than those already specified in (a)) with whom doctor intends to practise.
10. Whether applied/intending to apply for inclusion on minor surgery list/child health surveillance list.
11. Notification of proposed practice area (including appropriate map).
12. Notification of proposed practice premises.
13. Notification of proposed days and hours of attendance.
14. Proposed place of residence (including telephone number and distance from main surgery) and an undertaking to inform the Board whenever changing permanent residence.
15. Telephone number(s) at which prepared to receive messages.
16. Undertaking that if accepting as a patient a person who at the time of acceptance is residing at a place outside the practice area that he will visit him at that address.”.