HR- Outcome of Referrer Privileges Application

"*" indicates required fields

Unique ID

Please ensure that you check the name and professional body registration, as well as any restrictions on the registration, before issuing privileges.

Application is for*

Medical IRMER Referrer

Non-Medical IRMER Referrer

Approval Date

Practitioner Details (All)

Full Name ( same as Professional Body Register)*

Title*

Initial*

Surname*

Position*

Speciality*

Role (NMR)*

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Role(MR)-HIDDEN

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Role (HIDDEN)

Professional Register Body*

Professional Registration No*

Is Imaging Request in line with the scope of work*

Practice Address*

Email*

Contact No*

ICO No*

Has the recognised Radiation Protection training been completed?*

Non-Medical Referrer IRMER Training

Which Radiation Protectioon Training is completed?*

Has Radiation Protection Certificate been received?*

Please state which training*

IRMER Training Completion Date*

IRMER Training Expiry Date*

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Year of Completion (RP)- ARCHIEVED

Aplication Assessment

Outcome*

Please record on the PPS as shown below:

Practitioner: Radiology Department
Location: Imaging
Department: IRMER Referrers

Unique Referrer ID.*

See instructions how to create a Unique Referrer No

Please confirm Referrer ID is recorded in the PPS Staff database?

Any Notes

Meditice Access Details

Is Meditice Access required?*

Meditice Login

Meditice Password

Staff Details

Staff Name

Role

Signature*