Online Medical Work Experience for Medical School Preparation

Student Name*

Student Name*

Date of Birth*

Nationality*

Pre Existing Medical Conditions

Email Address *

Student Name*

Email Address *

Dietary Requirements *
Please let us know of any dietary requirements you may have

Medical Conditions
Let us know if you think we should know about any pre-existing medical conditions. All of our staff will be made aware of them and include any allergies or medication you may be taking.

Emergency Contact Details *
Please provide the name, contact numbers, email address and postal address of someone who you would like us to contact in case of an emergency

Anything Else?
Is there anything else you think we should be aware of/you would like us to know before your placement?

Please submit your details to notify us that you do not wish to purchase a meal plan for your course, thank you.

Email Address