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Title
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First name
Last name
Membership number
Email address
What country will you be working in?
Start date
End date
Please provide details of your work there, e.g. Type of work, who you will be working for.
What is your level or responsibility
Please provide details of any training relevant to this role.
How much are you paid?
Do you have indemnity for this work?
Yes, provided by the employer/organisation
No, indemnity cannot be sourced in the country
No, but indemnity can be sourced in the country
Please provide details of any work involving new or experimental treatment
Please provide details of any working involving the prescribing of any drugs off-license.
If you are a junior doctor, how will you be supervised?
Direct
On site
By telephone
Unsupervised
What is the grade of the supervisor?
Are you doing any of the following whilst overseas?
Demonstrating a procedure for the benefit of local practitioners
Providing treatment to a patient or patients that would not otherwise be available in that country
Cosmetic medicine/surgery
Highly paid work in a developed country
Neurosurgery
Obstetrics
Orthopaedics
Teaching/educational work
Please provide any other relevant details:
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