Practitioner Application

Thank you for becoming part of a community connecting patients to doctors remotely. Please complete the form accurately for due diligence checks.

We look forward to working with you.

PractitionerAppForm (#5)

Practitioner Name

Middle Name

Last Name

Contact Number

Correspondence Address

Address Line 1

Address Line 2

City

State

Zip / Post Code

Country

Company Name

Gender

If you selected 'Other' for your gender, please state your gender here.

Areas Of Specialisation

Confidentiality Agreement

Tick this box to agree: For so long as this Agreement is in effect and for two (2) years after its expiration or termination, the Practitioner will consider as confidential any information, disclosed in tangible, electronic or oral form. The Practitioner agrees to receive and maintain all Confidential Information in strict confidence using at least reasonable care. Confidential Information may be used by the Practitioner only in furtherance of the purposes of this Agreement and may not be delivered or disclosed, in whole or in part to any third party. During the term of this agreement and for the period of two (2) years after termination, the Practitioner will not either directly or indirectly on its own behalf or in the service or on behalf of others solicit, divert, or hire away, or attempt to solicit, divert, or hire away any client referred by the company or any person employed by the company.

Consent

Tick this box to agree: By signing this agreement, you (the practitioner) consents to The School Of BioNatural Medicine holding and processing information for legal, personnel, administrative and management purposes and in particular to the processing of any sensitive personal data (as defined in the Data Protection Act 2018, incorporating the GDPR) including, as and when appropriate: a) information about your (the practitioner) physical or mental health or condition in order to monitor sick leave and take decisions as to his/her fitness to perform his/her duties; b) information that may be relevant to ensuring equality of opportunity and treatment in line with The School Of BioNatural Medicine’s equal opportunities policy and in compliance with equal opportunities legislation; and information relating to any criminal proceedings in which the practitioner has been involved, for insurance purposes and in order to comply with legal requirements and obligations to third parties. c) consent to the transfer of such personal information to other offices The School Of BioNatural Medicine may have [or to a company in the Group] or to other third parties, whether or not outside the European Economic Area, for administration purposes and other purposes in connection with your (the practitioner) appointment, where it is necessary or desirable for The School Of BioNatural Medicine to do so.

Referral Number / Full name of person who referred you to our organisation.

Tick this box if you agree to have your name, picture and a brief bio of you on our website and other marketing materials.

Yes, I agree to be on your website and promotional materials.

Please note: We would require the below listed items to be uploaded as part of your application in order for you to be fully registered with the School Of BioNatural medicine.

Proof Of ID (Passport / Driving Licence)
Proof of address (Bank Statement / Council Tax Letter / HMRC Letter)
Practicing Licence
Proof of Qualification/Training Certificate
CV / Linked Profile
Proof of Professional Liability Insurance
Disclosure and Barring Service and/ Police report
Medical Certificate
Two professional references

Please be aware that your name on your ID must match the name you applied with. If your practicing name differs to your ID, please also send a solicitor-certified copy of your birth certificate.

If you have any query with your uploads, please email via info@schoolofbionaturalmedicine.co.uk and our team will be happy to assist.

File Upload - Please upload as a single file scan of all documents in one pdf

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File Upload - Please upload as a single file scan of all documents in one pdf

Choose File