Live Registration Request Form for BRIT

Delegate Registration 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:

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

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 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

In collaboration with