Online Request for Locum Assistance form

Application Details
GP Name
Practice
Address
Tel
Fax
Email

Locum Requirements
Date for which Locum assistance is required
From   To 
At what time and on what date will the Locum be expected to commence duty
At what time and on what date will the Locum cease duty

Practice Information
How many consulting sessions do you work per week?
How many GPs are working in your practice:
Up to 6 sessions per week?   7 or more sessions per week? 
Do you share a hospital after-hours on-call roster with other GPs in your region? Yes  No
If Yes, which Hospital?
Do you provide an after-hours on-call service exclusively for your own patients? Yes  No
In the event that a Locum is available, what type of accommodation would be offered to the Locum?
Hospital Flat  B&B  Holiday Unit  Other Accommodation  
If other, please provide details

Locum Requirements

The Locum would be required to work the following sessions:
10 sessions Monday to Friday (inclusive of consulting/hospital rounds/outpatients)
9 sessions Monday to Friday and Saturday to midday (inclusive of consulting/hospital rounds/outpatients)
Please give an indication of the after-hours on-call that may be expected of the Locum:
Not Required      Continuous(24/7) 1 night per week 
2 night per week 3 night per week  Middle Weekend
Will the Locum be required to work at a branch practice?
Yes  No
If yes, please provide branch practice details:
Please provide any other information that may be of assistance regarding your request:
Form Completed by: GP Principal   Practice Manager
By clicking the "Submit Request" button below, your request for Locum assistance details will be recorded. Please be assured that your details will be kept in the strictest confidence and will not be given to any other third parties.