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Name

GMC number

Phone

E-mail

Date of birth

Date started private practice

Current provider

Current premium

No. of years with current provider

Required start date

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Coming years estimated gross private practice income

Coming years estimated gross Medico Legal income

Approximate number of procedures performed in the last year:

Approximate split between consultations and procedures performed in the last year:

Do you treat any elite/professional sports people or high profile (media, TV etc) patients?

Yes

Do you plan to cease practice or do you have any retirement plans (Private Practice, NHS or Medico Legal):

Yes

Have you ever been or are you currently subject to any complaints, claims, disciplinary investigations or circumstances which could lead to a claim, either in the UK or overseas:

Yes

Corporate Social Responsibility

Primus Medical Indemnity Ltd
Lake View House,
Wilton Drive,
Warwick,
CV34 6RG.

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Your Practice

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