Application for Enrolment with the Strategic Planning & Performance Group, Department of Health

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Ophthalmic Contractors & Individual Ophthalmic Practitioners Privacy Notice
Declaration*
I have read and understand the Privacy Notice

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Optometrist - General Ophthalmic Services

To enrol with the Strategic Planning &Performance Group (SPPG) please complete all relevant sections of this form. After the completed form has been received and reviewed, an induction with the Optometry Staff of the SPPG will be arranged.

Please note you cannot provide General Ophthalmic Services (GOS) until you have been issued with a personal code.
Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Dispensing Optician - General Ophthalmic Services

To enrol with the Strategic Planning &Performance Group (SPPG) please complete all relevant sections of this form. After the completed form has been received and reviewed, an induction with the Optometry Staff of the SPPG will be arranged.

Please note you cannot provide General Ophthalmic Services (GOS) until you have been issued with a personal code.
Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Ophthalmic Medical Practitioner - General Ophthalmic Services

To enrol with the Strategic Planning & Performance Group (SPPG) please complete all relevant sections of this form. After the completed form has been received and reviewed, an induction with the Optometry Staff of the SPPG will be arranged.

Please note you cannot provide General Ophthalmic Services (GOS) until you have been issued with a personal code.
Part 1 - Personal Details
Forename(s)*
Surname*
Previous Surname(s)
Private Address*
Private Address Town/City Postcode
Telephone Number*
Email Address*
Please remember to use upper and lower case as appropriate for email
Enter Email Confirm Email
Please note that the Strategic Planning & Performance Group (SPPG) and Business Services Organisation will use the above details to contact you. Please ensure that you inform the Business Services Organisation of any changes to the above details.

Part 2 - Ophthalmic Qualification(s) / Registration as a Optometrist in the UK
Qualifications*
Date University Optometry Degree gained*
DD slash MM slash YYYY
Date of UK registration as an Optometrist*
DD slash MM slash YYYY
General Optical Council Number*
Your GOC registration status will be confirmed prior to enrolment.
Further qualifications held
- Independent Prescriber
- Professional Certificate in Glaucoma (College of Optometrists)
- MECS 1
- MECS 2
- Cataract Training (WOPEC or Ulster University programme)
- Other
Date Independent Prescriber qualification gained*
DD slash MM slash YYYY
Date Professional Certificate in Glaucoma gained*
DD slash MM slash YYYY
Date MECS 1 gained*
DD slash MM slash YYYY
Date MECS 2 gained*
DD slash MM slash YYYY
Date Cataract Training (WOPEC or Ulster University programme) gained*
DD slash MM slash YYYY
Cataract Training (WOPEC or Ulster University programme) please specify:*
Please specify other*
Please include date(s) gained
Part 2 - Ophthalmic Qualification(S) / Registration as a Dispensing Optician in the UK
Qualifications*
Date this qualification was gained*
DD slash MM slash YYYY
Date of UK registration as a Dispensing Optician*
DD slash MM slash YYYY
General Optical Council Number*
Your GOC registration status will be confirmed prior to enrolment.
Further qualifications held
- Certificate in Contact Lens Practice
- Other
Please specify other*
Please include date(s) gained
Date Certificate in Contact Lens Practice gained*
DD slash MM slash YYYY
Part 2 - Ophthalmic Qualification(S) / Registration as a Doctor in the UK
Qualifications*
Date this qualification was gained*
DD slash MM slash YYYY
Date of U.K registration as a Doctor*
DD slash MM slash YYYY
Date approved by the Ophthalmic Qualifications Committee as an Ophthalmic Medical Practitioner
DD slash MM slash YYYY
General Medical Council Number*
Your GMC registration will be confirmed prior to enrolement.

Name of NHS Commissioning Organisation	Address of NHS Commissioning Organisation	Phone number of NHS Commissioning Organisation	Email address of NHS Commissioning Organisation

Application for Enrolment with the Strategic Planning & Performance Group, Department of Health – 20 a/b/c

Step 1 of 6

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Optometrist - General Ophthalmic Services

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Dispensing Optician - General Ophthalmic Services

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Ophthalmic Medical Practitioner - General Ophthalmic Services

Part 1 - Personal Details

Please note that the Strategic Planning & Performance Group (SPPG) and Business Services Organisation will use the above details to contact you. Please ensure that you inform the Business Services Organisation of any changes to the above details.

Part 2 - Ophthalmic Qualification(s) / Registration as a Optometrist in the UK

Part 2 - Ophthalmic Qualification(S) / Registration as a Dispensing Optician in the UK

Part 2 - Ophthalmic Qualification(S) / Registration as a Doctor in the UK

Part 3 - Northern Ireland Employment / Practice Information

Part 4 - Declarations

Part 4a Health Clearance

Part 4b Previously / presently delivering general ophthalmic services

Part 4c Declarations

Part 4d Consent

Name	Address	Premises Code

Application for Enrolment with the Strategic Planning & Performance Group, Department of Health – 20 a/b/c

Step 1 of 6

Application for Enrolment with the Strategic Planning & Performance Group (SPPG) Optometrist - General Ophthalmic Services

Application for Enrolment with the Strategic Planning & Performance Group (SPPG) Dispensing Optician - General Ophthalmic Services

Application for Enrolment with the Strategic Planning & Performance Group (SPPG) Ophthalmic Medical Practitioner - General Ophthalmic Services

Part 1 - Personal Details

Please note that the Strategic Planning & Performance Group (SPPG) and Business Services Organisation will use the above details to contact you. Please ensure that you inform the Business Services Organisation of any changes to the above details.

Part 2 - Ophthalmic Qualification(s) / Registration as a Optometrist in the UK

Part 2 - Ophthalmic Qualification(S) / Registration as a Dispensing Optician in the UK

Part 2 - Ophthalmic Qualification(S) / Registration as a Doctor in the UK

Part 3 - Northern Ireland Employment / Practice Information

Part 4 - Declarations

Part 4a Health Clearance

Part 4b Previously / presently delivering general ophthalmic services

Part 4c Declarations

Part 4d Consent

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Optometrist - General Ophthalmic Services

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Dispensing Optician - General Ophthalmic Services

Application for Enrolment with the Strategic Planning & Performance Group (SPPG)
Ophthalmic Medical Practitioner - General Ophthalmic Services