Application Form

Part 1: Personal details

Part 2: Professional Details

From which Dental School did you qualify?

What year did you qualify?

If you were a Vocational Trainee, where did you do this VT period?

Name of your VT Trainer?

Do you have post graduate qualification/s?

Qualification/s gained

Year/s

Are you included on the `specialist list`? If so, what do you Specialise In?

Professional Indemnity insurance company

PVG No

Membership/Policy Number

Part 3: Complaints/Litigation

A. Are there any complaints or legal issues in respect of you as a dentist or circumstance that could affect you professionally?

Current
Pending
Past

Yes No

B. If You Have Answered ‘yes’ To Part A Of This Question. In The Section Below Give Detals / Dates / Circumstance /outcome

Part 4: Current/Outstanding Core Cpd Training Requests

Hdp Are Committed To Continuous Professional Development. This Answer Will Help Guide Our Cpd Course Curriculum.

Part 5: Practice Details

How Long Has The Practice Been In Existence?*

How many dentists are in your practice?*

Are You Compliant With Health And Safety? *

If you have a satellite practice or practices please complete details below:

Part 6: References

Professional - Clinician From A Practising Situation Over The Past Ten Years (Must Have Known You At Least 2 Years Or Been Your Vocational Trainer) And Have Relevant Experience In Providing Quality Uk Dentistry.

Part 7: Joining Agreement

Agree To Abide By The Rules And Conditions Of Membership Of Highland Dental Plan Limited

Agree That Membership Is Entirely At The Discretion Of The Management Committee

Agree That Should There Be Litigation Or Complaint Against Me In The Future The Management Committee Will Be Made Aware Of This Immediately.

Please upload a copy of your GDC Registration and PI Insurance documents

GDC Registration File

PI Insurance

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