Loc IUT Doctors booking form

Entry Requirements

UK GMC Registration Number:

I have a license to practice with the UK GMC: YesNo
I have passed the eKA or I hold one of the following:a DFSRH, NDFSRH or FFSRH that was gained or has been recertified within the last five years.

Please select which of the options applies to you from the following drop-down box:
I have posted/emailed a copy of my:---eKA pass certificateDFSRHMFSRHFFSRH

I am competent in consultation skills

I will complete e-SRH Module 18 before my clinical training session at Leeds Student Medical Practice

I have posted or emailed evidence of e-SRH Module 18

I am up to date with resuscitation and analphylaxis including competent to give intramuscular injections

I have posted or emailed cericates of completion of anaphylaxis training and basic life support training

I am competent in assessing the size, position and mobility of the uterus

I am competent in assessing, investigating and managing potential IUS users with abnormal findings at a pelvic exam, heavy and /or painful periods, infrequent and / or absent periods, vaginal discharge and sexual transmitted infections and acute and chronic pelvic pain

I agree that I meet all the entry requirements: yesno

Timeframes

I will apply for my LoC within three years of passing the eKA: yesno

I will start model uterus / clinical assessments within two years of my eKA pass: yesno

I will start model uterus / clinical assessments within six months of completing the e-SRH Module 18:
yesno

Reading

I have read and understand the FSRH "Training requirements for the letter of competence in Intrauterine Techniques (Loc IUT) IUT Training Requirements

I have read and understand the FSRH "Learning Outcomes for the Letter of Competence in Intraterine Techniques IUT Learning Outcomes

I have read and understand the FSRH "General Training Terminology"-http://www.fsrh.org/pdfs/general training terminology

I have read and understand the FSRH "Record of Training for the Letter of Competence in Intrauterine Techniques (LoC IUT)"- http://www.fsrh.org/pdfs/IUT Trainingrecord

I have read and understand the FSRH 2Uodate to Faculty of Sexual and Reproductive Healthcare (FSRH) Training Programme Changes to the FSRH Diplomat Assessment/Letters of Competence Frequently Asked Questions" - http://www.fsrh.org/pdfs/FAQsUpdateFSRHTrainingProgramme

I agree i have read all the suggested reading: yesno

Fees

I am aware that there is a fee payable to the Faculty for the LoC IUT

I agree that if I attend my sessions unprepared, my training may be cancelled and my payment may still be taken.

I agree that my payment for £450 is for three practical training sessions which is the usual number of sessions it takes in order to reach the satisfactory standard required to complete the training. Should I require further training in order to meet the required standard there may be additional charges.

I understand that should I require any additional sessions following this, Leeds Student Medical Practice will charge me £100 for each additional practical training session.

Insurance

Medical defence organisation (please write the name of the organisation you are covered by):

I confirm that I am covered by my medical defence organisation for the duration of my training:
yesno

I understand that in order to obtain a parking place in the visitors' car park at Leeds Student Medical Practice I must collect a parking permit from reception and display it in
my vehicle before commencing training. Failure to do so may result in a fine of £80.

I understand that parking may not always be available at Leeds Student Medical and in these circumstances I will have to make my own alternative arrangements.

Leeds Student Medical Practice reserve the right to cancel LoC IUT training sessions if there are insufficient patient numbers and /or in the event of unforeseeable
circumstances adversely affecting your training sessions.

I agree to the terms and conditions of the Fees section yesno