For any Compulsory fields marked * which do not apply to you, enter N/A.
Other than HCA please list the private hospital groups you withwhom you have admitting rights. Select from the following list. If no relevant healthcare group is present or you only work in Independent private hospitals, please select "Other"
Please provide the % breakdown of your work between the following categories
Please advise your Total Gross Annual Income from Private Practice
Please provide a split, where applicable, of your Private Practice (%by number of sessions) between (the combined sum of all the fields must be 100%):
How many sessions per week do you practice (1 session = 4 hours)
Please provide the following details in relation to both NHS and Private Practice
Are you currently aware of, or have you ever been the aware of in the past, either wholly or in part, either in the UK or abroad, any of the following:
Please provide any additional information on any other treatments offered, or any other information you believe will be relevant to your application:
for completing the online application process for Practitioner Select Insurance, a trading name of Integro Insurance Brokers Ltd.
Your application will be reviewed over the next 3 working days.
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