General Practice Fellowship Role Expression of Interest Form

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* 1. Practice Details:

Name of practice:

Address:

Name of Practice Manager:

Email address:

Contact number:

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* 2. Details about your practice:

Borough:

List Size:

Number of partners:

Number of doctors:

Other clinicians in the practice:

Practice ethos

Training and Development Opportunities available to prospective Fellow

Anything else you would like the prospective Fellow to know

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* 3. How many sessions are you looking to recruit a GP to work in your practice?

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* 4. What is the minimum number of sessions you would accept?

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* 5. To host a GP Fellow the practice must agree to release the Fellow for one session a month on a Wednesday afternoon to attend the peer-support scheme provided by HEE.
I accept that this is a requirement of participating in the Fellowship programme.

Yes

No

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* 6. Please indicate the date/s you would want the Fellow to commence in post

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* 7. Please state the name and give contact details of the most appropriate person to contact regarding the Fellowship programme:

Name:

Contact details: