BSACI - Live Registration Request Form for BRIT

Live Registration Request Form for BRIT

As a Consultant

As a Delegate for a Consultant (please note that we will need permission from your consultant to add you as a delegate to their records)

Title:

First Name

Last Name

E-Mail

Contact Number

Specialist accreditation:

Are you a consultant or equivalent grade practitioner

Yes

GMC or NMC Pin Number

What is your main place of work?

Primary Medical Registered Specialty?

Do you give permission to allow delegate users from these practices access to your patient records

Yes

Permission to allow other consultants from your practice(s) access to your patient records

Yes

Primary Hospital

Department/Services

Examples:
Primary Hospital: St. Thomas’s Hospital
Department/Service: Evelina Children’s Hospital
Or
Primary Hospital: University Hospitals of Leicester NHS Trust
Department/Service: Leicester Adult Allergy Service

Additional Hospitals (if any)

If we/BSACI or our third party data controllers need to communicate with you are you happy to be communicated by:

Phone

Mail

To register you will need to be a BSACI member, to find out more about becoming a member please click here.

We will contact your consultant (s) to get permission for you to have access to their registry patients, please give as much detail as possible so that we can find them on the system

Consultant Name

Consultant Surname

Consultant Email

Primary Hospital

Department/Services

Additional Hospitals or Consultants (if any)

If we/BSACI or our third party data controllers need to communicate with you are you happy to be communicated by:

Phone

Mail