PERSONAL INFORMATION
Name:
Address:
Telephone
Preferred (please select)
Home:
Work:
Mobile:
Private:
Email:
Current position and location:
Do you have any previous experience of medical legal work?
Yes
No
If yes, please specify
Availability (please select the boxes below to indicate your availability for medical reporting)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning (9pm-12pm)
Afternoon(1pm-5pm)
Full Day
Other (please specify)
