DECLARATION

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for MK Medical Solutions to make recommendations to my employer.

I understand that the information contained within this document is governed by the Data Protection Act 1998 and that disclosure of information will occur only in relation to employment opportunities. I understand that you may send essential information to my

potential employer and make recommendations regarding any health or hazards and risks to any future employment with reference to other relevant statutory requirements and professional practice.

I confrm that I am aware of the GMC's statement with regard to the duties of infected doctors or doctors who have reason to believe that they may be infected with the HIV virus or MRSA and agree to notify the agency should my circumstances change.

I confrm that I am aware of the NHS guidance and recommendations with respect to serious communicable diseases including Rubella, Varicella, TB, Hepatitis B and Hepatitis C and agree to notify my employing hospital and the agency should I have any reason to suspect that I may be at risk to patients, carers or other healthcare workers.

I understand that my pathology/serology reports may be sent to any NHS Trust where I may be assigned for locum work.

I agree to inform the agency of any health projects or changes to my status, for example become pregnant, so that my health and safety can be protected whilst at work.

Registration form