On-line Registration

For a fast & easy way to register with Medirec just complete this form and attach your CV as requested at the end of the form. Once received we'll acknowledge receipt and get your registration processed. Should you have any questions whilst completing the form then do not hesitate to contact a member of our team at Medirec on +44 (0)870 321 8844 or email us at registration@medirec.com 

Surname: Mr / Mrs / Miss / Dr:
Forename(s) Previous Surname(s)
Gender: Male   Female   Date of Birth:
Profession: Speciality:
Address: Post Code:
  Country:
Preferred Tel: Mobile Tel:
Home Tel: Work Tel
Fax Number: E-mail Address:
Next of Kin: Next of Kin Tel:
Nationality: Country of Origin:
How did you hear about Medirec?

To help us find the most appropriate work for you, please answer the following questions:
What are your preferred areas of speciality?
Are there any areas you would not consider?
What type of work are you looking for (please tick)? Full Time   Part Time   Contact
In which geographical areas would you prefer to work?
Would you be prepared to live in hospital accommodation: Yes   No
Do you hold a current driving licence and if so what type? e.g. British, International
Do you have your own means of transport?
If currently working full-time, how much notice are your required to give?
What is your current hourly pay rate or annual salary?

Please select ONE of the following:
UK Passport: Working Holiday Visa UK Ancestry Visa
Work Permit: Accompanying spouse Visa Permit-free training
Spouse of permit holder: Practising doctor in the UK before 01/04/1985    
Other Passport: Which other Country's passport?  

Institution Qualification Date Commenced Date Qualified
       
Are you a member of any professional bodies e.g. GMC/HPC/GSCC/AODP/RPSGB/CSP: Yes   No
If yes, please give details:
Professional body registration number: i.e. for GMC/HPC/GSCC/AODP/RPSGB/CSP: Expiry date:
If you are a Doctor, are you on the specialist register? Yes   No
If yes, NTN/VNTN number:
Please give details of your medical defence organisation MDU/MPS etc.:    
  Organisation:  
  Policy Number:  
  Renewal Date:  

Employer / Organisation Dates (from/to) Grade Post Area of responsibility

Please give the names and addresses of your referees. One referee should be your current or most recent employer. If you would like us to check with you before contacting your referees please check this box:
Referee number 1   Referee number 2  
Name: Name:
Position: Position:
Address: Address:
Tel: ext: Tel: ext:
Fax: Fax:
E-mail: E-mail:

Have you completed an approved lifting/manual handling programme? Yes   No Date:
Have you completed a course in Basic Cardiopulmonary Resuscitation? Yes   No Date:
Have you completed a course in Advanced Cardiopulmonary Resuscitation? Yes   No Date:
Have you completed a course in Control & Restraint Techniques? Yes   No Date:

Course Name Location Date Additional Information
If you do not have a CV to upload at the end of this Registration Form you can use the field marked Additional Comments at the bottom of this page.

What is your Height? What is your Weight?
Do you currently, or have you in the past suffered from any disorders relating to the following systems?
Respiratory (including asthma, pneumonia, breathless or allergies) Yes   No
Cardiovascular (including high blood pressure or chest pains) Yes   No
Gastrointestinal (including dysentery, typhoid or any skin infection) Yes   No
Central Nervous (including headaches, migraine, fits or epilepsy) Yes   No
Genito-urinary (including any kidney or bladder infections) Yes   No
Dermatological (including eczema, dermatitis or any skin infection) Yes   No
Endocrinology (including diabetes, thyroid or gland disorder) Yes   No
Haematological (including low red blood cell count) Yes   No
Locomotor (including rheumatoid arthritis, prolonged backache or disc trouble) Yes   No
Have you any known allergies? Yes   No
Have you ever taken an overdose of drugs? Yes   No
Do you have a history of mental illness? Yes   No
Do you have a medical condition affecting sleep? Yes   No
Is there any medical reason why you should not work at night? Yes   No
Are you pregnant? Yes   No
Have you any reason to believe that you should not work currently, for example:  
Exposure to notifiable disease? Yes   No
Are you currently under medical supervision or taking any medication? Yes   No
Have you ever been treated for abuse or addiction to any substances? Yes   No
If the answer to any of the above questions is yes or you are currently taking any medication, please give further details:
Have you had any illness or operation not mentioned other than childhood illness? Yes   No
If yes, please give further details:
Would you be prepared to attend a medical examination? Yes   No
There may be times when we need further information from your Occupational Health
Department or GP, please tick the following box for your authorisation to do this.		 Yes   No
Are you hard of hearing or wear a hearing aid? Yes   No
Do you wear spectacles or contact lenses or have any defect of sight? Yes   No
How many days sick leave have you had in the last 12 months? Please give reasons and duration of each episode in the space below:
Most recent chest X-Rays
Do you smoke? Yes   No Amount: Daily:  Weekly:
Do you drink alcohol? Yes   No Amount: Daily:  Weekly:

Have you had any of the following vaccinations?
Hepatitis B Vaccine Yes   No Date:
Tuberculosis (B.C.G.) Yes   No Date:
Positive Heaf Test Yes   No Date:
Tetanus (Most recent booster) Yes   No Date:
Rubella Screening Test Yes   No Date:
Oral Polio Yes   No Date:
Typhoid Yes   No Date:
Diphtheria Yes   No Date:
Chicken Pox Yes   No Date:
Please also provide documentary evidence (a copy of original certification) or a letter from your G.P. together with this application form.
Hospitals in the UK may not employ healthcare workers unless they are able to produce documentary evidence regarding hepatitis B status.

Rehabilitation of Offenders Act 1974 (All applicants)
Virtually all the assignments we arrange are with clients who are exempt from the provision of section 4(2) of the Rehabilitation of Offenders Act 1974 (Exceptions/Amendments) Order 1985. Applicants are therefore not entitled to withhold information about any convictions which for other purposes are ‘spent’ under the provision of the Act. Any information given will be completely confidential and will be considered in relation to an application for the positions to which the order applies. Please tick the box below if you have no such convictions to declare. If not please contact us for advice.
I have no convictions to declare
Police Checks & CRB Checks (All applicants)
In positions where you will have substantial access to children, the sick or vulnerable you will be required to have a British Police Criminal Record check or CRB check, which will identify all past convictions, including those passed as “spent”. Please note: many employers now require a police check or CRB check for all healthcare professionals.
Do you have such a Police or CRB check? Yes   No
If you are from outside the UK, please apply for a police check in your home country before travelling to the UK. If you reside in UK please contact your nearest police station and request the following forms ‘Data Protection Forms: Request for access to Information held on Police Computers or go to the CRB website at http://www.crb.gov.uk/ .
Professional Misconduct (All applicants)
Have you ever been the subject of professional misconduct proceedings or suspensions from an employer, or are such pending or threatened against you either in the UK or abroad?
Yes   No
If yes please give details:
48 Hour Working Week Opt-out (All applicants except Doctors)
The working Time Directive states that staff cannot be forced to work more than an average of 48 hours per week. You are free to accept as many or as few hours per week as you wish. However, in case you should wish to work more than 48 hours in any one week, please sign below to give your consent.
I hereby agree that the Working Week Limit shall not apply: Yes   No
Ionising Radiation (Doctors only)
There is a requirement for certain medical practitioners to be in possession of a certificate (the Popumet certificate) to administer radiation. Do you hold the Certificate in Ionising Radiation?
Yes   No
AIDS / HIV infected healthcare workers (All healthcare professions)
I confirm that I am aware of the Department of Health’s guidelines on AIDS/HIV infected healthcare workers issued in April 1993 and agree to abide by these recommendations. (tick box below)

In order for us to process your application we will require a copy of your current CV.
If you would like to submit your CV online please use the browse button below.
You can fax your CV to us on +44 (0)870 321 8850 or send us your CV by post to:

Medirec Recruitment
1 The Shrubberies
George Lane
London
E18 1BE


I declare that all the information I have provided above is correct and that I will immediately notify Medirec of any changes.
(you must agree to this in order to submit this form)