Clinical enquiry form

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If you have a clinical question, 绿帽换妻 Learn brings you instant access to the latest nursing, social and health care learning resources from the 绿帽换妻 and 绿帽换妻i.

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If you are in dispute with your employer over a clinical issue, please use our Problems at work checklist for the steps to take to resolve this.

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Contact details

Can we update your personal details if any of the below information does not match the data we currently hold on your record? Yes No Full name: 绿帽换妻 membership number: Address: Best contact number:

Please note that 绿帽换妻 Direct will not usually call you. Where an onward referral is required, provided you were in the correct category of membership at the time of the incident, we will provide these contact details to the 绿帽换妻鈥檚 Nursing Department.

Do you give us your consent to pass on this information? Yes No Can we leave you a voicemail? Yes No Can we contact you on this matter by email? Yes No If we need to pass your enquiry to your local 绿帽换妻 office or a specialist 绿帽换妻 department, would you like any emails from them to be password protected? Yes No Email address you would like us to reply to Please confirm the email address you would like us to reply to Please list any times that you are unavailable for calls during the next week (9am-5pm):

Employment details

Please write out in full, don't use acronyms.

Place of work Employer On what date did you start working with your current employer? Ward or department Job category

Please confirm that you work under the supervision of a registered nurse, midwife or health visitor. If you do not, please call our 绿帽换妻 team on 0345 772 6100 as you may not be eligible for 绿帽换妻 membership.

Job title Band Weekly contracted hours Do you have any meetings scheduled? Yes No If yes, please give date, time and location: Are you already being supported by a rep? Yes No If yes, please include details below: Are you in the UK on a visa? Yes No If yes, please include details below (including how long you have been in the UK and when your visa expires):

Clinical/nursing

Practice setting: Enquiry details: What does your local policy say about this? Have you discussed your enquiry/issue with your employer? If yes, what was their response? What actions have you taken so far? Incident date (if not applicable, please select today鈥檚 date):

By submitting this form, you are giving the 绿帽换妻 permission to contact you about your submission.

You can control the information you receive from the 绿帽换妻 by updating your preferences at My绿帽换妻.

We don’t update your contact details unless you ask us to. The best way to check and update the details we hold for you is by visiting My绿帽换妻.

The information you provide in this form will be stored by the 绿帽换妻.

Protecting your privacy is very important to us. Please view our privacy policy to find out more about the information we collect and how it is used.

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