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Medical Student Placement

Please complete the information below BEFORE starting your placement with us!

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Surname:

Name:

Supervising Doctor (Primary):

Medical School:

Placement START:

Placement FINISH:

Photo ID (Driver's Licence, Student Card, etc.)

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Vaccination Record (incl. Hep Serology)

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Working With Children Check (WWCC) Number:

I agree NOT to divulge any personal or confidential information concerning: patient personal, health or financial information; any of the dealings, transactions or affairs relating to my supervising clinician or Church Street Management Provider Pty Ltd

I agree.

I agree to abide by the service provider's policies regarding infection control, contact tracing and site access for the duration of my placement

I agree.

I agree that any access to confidential medical information is strictly under the direction of my clinical supervisor, and that accessing records beyond this direction may result in disciplinary action by my clinical school, or legal proceedings by Church Street Management Provider Pty Ltd.

I agree.

Medical Student Placement

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CONTACT

ADDRESS

HOURS