Primary Care Clinic /Centre Health Professional Registration Form
Health Professionals referred to hereunder as Qualified Persons include GPs, GP Registrars, Registered Nurses on the General Nurse Division or Midwives Division of the Nurse and Midwifery Board of Ireland (NMBI) Register
The Qualified Person acknowledges and agrees that Programme cervical screening tests will be carried out under the clinical responsibility of the Clinical Director below pursuant to the Contract for the Provision of Cervical Screening Services entered into by the Clinical Director on behalf of the Clinic/Centre with the National Screening Service. The contracted Clinic/Centre shall receive payment for all such tests carried out.
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Health Professional

Name of doctor or nurse
(BLOCK CAPITALS)	     Male	    Female	

Clinic/Centre Name
(BLOCK CAPITALS)

Please specify	GP                       GP Registrar                 Registered General Nurse                Registered Midwife  

Personal Email address
   
    I consent to the use of this email for administrative communications from CervicalCheck			Yes	             No 
   (Administrative communications will include information on policy updates, study days, news-letters etc)

I have completed the ‘CervicalCheck in Practice’ online Introductory eLearning module		
   Mandatory for new registrations with effect from 01/09/2022
   Mandatory for existing registrations with effect from 01/09/2023

Medical Council  Registration Number (MCRN) or  Nursing & Midwifery Board of Ireland Number (NMBI)

Signature of the Doctor / Nurse	Date

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Clinical Director

Name (BLOCK CAPITALS)

Medical Council  Registration Number (MCRN)

PCERS NUMBER (GMS) of Clinic/Centre

Signature of Clinical Director	Date

The Qualified Person and the Clinical Director will be notified when the QP registration process has been completed. 
It is important to notify Programme Administration Office of any changes to your details or professional registration status.
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For office use only

Date stamp

Check 1	Date

Check 2	Date

Assigned Clinic ID	C	L	I	N					
CS/F/A-15 Rev 10

PO Box 161, Limerick.
    Phone: 061 40650
Cuid d’Fheidhmeannacht na Seirbhíse Sláinte.  Part of the Health Service Executive.	Email: admin@cervicalcheck.ie www.cervicalcheck.ie