IOM Existing Member Form

Membership Number GMC GDC Number Email Are you a Partner in a GP practice? If yes, how many sessions per week? Do you hold a Salaried GP role? If yes, how many sessions per week? Do you work any Locum GP sessions? If yes, how many sessions per week? Are any of the afore mentioned sessions in an Out Of Hour's (OOH’s) setting? If yes, how many sessions per week? Do you undertake any Private GP Sessions? If yes, how many sessions per week? Do you undertake any Private Health Assessments? If yes, how many sessions per week? Do you undertake any Private Online Consultations? If yes, how many sessions per week? Do you undertake any Cosmetic Medical Procedures (i.e. breast uplift/reduction, Rhinoplasty, liposuction, etc)? If yes what is your gross annual income from this work? Do you undertake any Aesthetic Medical Procedures (i.e. botox, dermal rollers, fillers, etc.)? If yes what is your gross annual income from this work? Do you undertake any Forensic Medical Examiner or Police Physician work? If yes what is your gross annual income from this work? Do you undertake any Medico-Legal/Expert Witness Report writing? If yes what is your gross annual income from this work? Do you undertake any Occupational Health work (outside of standard NHS practice)? If yes what is your gross annual income from this work? Do you undertake any Sports Medicine (including crowd Doctor) work? If yes what is your gross annual income from this work? Do you undertake or run any private travel medicine/clinics (Outside of standard NHS practice)? If yes what is your gross annual income from this work? Do you undertake any Non-NHS or Charity based Hospice or Palliative care work? If yes, how many sessions per week? Do you undertake any non-clinical work (i.e. Clinical Director, Clinical Lead, etc)? If yes, how many sessions per week? Do you undertake any other non-NHS or Private work we should be aware of? f yes, please provide full details... How many sessions per week? Gross annual income for other non-NHS or Private work Do you undertake any Covid-19 vaccination work? If yes, please provide details of the specific indemnity arrangements that are in place.

I acknowledge that by completing and submitting this form I am joining the Manx Care Clinical Indemnity Scheme and that my MDDUS indemnity liabilities (if any) will be transferred to the Manx Care Clinical Indemnity Scheme (under the GDPR lawful bases of contract and legitimate interests). Please tick the box below to confirm and proceed.

I acknowledge the above statement and agree to proceed.

If you wish to move your retrospective liabilities from either MDDUS or another medical defence organisation to the Manx Care Clinical Indemnity Scheme, retrospective with effect from 1st April 2019 please tick the box below and enter the date from which you wish to transfer liabilities.

I wish to move my retrospective liabilities Date from which you wish to transfer liabilities.

***Aesthetic Procedure List

Botox; Non-permanent dermal fillers for use in the treatment of facial wrinkles and/or lip enhancement. All fillers must be manufactured to CE standards and consist of highly purified bovine or human collagen, Hyaluronic acid gel, Calcium hydroxylapatite, or Poly-L-lactic acid (PLLA); Superficial chemical peels (only affecting the intra-epidermal layer); Microdermabrasion / hydrodermabrasion / Dermaroller; Sclerotherapy injections for the treatment of thread veins on the trunk and limbs; IPL (Intense Pulsed Light); Non-ablative radiofrequency treatments.

GPs undertaking work not included in the list above should contact MDDUS for a personalised quote prior to commencing any treatment.

Manx Care Clinical Indemnity Scheme is provided by The Medical and Dental Defence Union of Scotland (MDDUS). Other aspects of the full range of products and services that are available to MDDUS members may be provided by other MDDUS Group companies.

MDDUS Group is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us.

From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below if you would like to receive these communications:

I would like to receive updates for services and products

MDDUS needs the contact information you provide to us to contact you about our products and services. You may unsubscribe from these communications at any time. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, please review our Privacy Notice.

By clicking submit below, you consent to allow MDDUS to store and process the personal information submitted above to provide you the content requested.