Registration Form - NENC Pharmacy Network NHS Future Platform

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1. Question 1.

First Name

Required - Required.

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2. Question 2.

Surname / Family Name

Required - Required.

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3. Question 3.

Your title

Required - Required.

Mr

Mrs

Miss

Ms

Other (please specify):

This is required

Input box for - Other (please specify):

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4. Question 4.

Email address (NHS email preferred)

Required - Required.

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5. Question 5.

Are you UK registered pharmacy professional?

Required - Required.

Yes

No

Other (please specify):

This is required

Input box for - Other (please specify):

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6. Question 6.

Which PCN are you involved with?

Required - Required.

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7. Question 7.

Who is your PCN Lead Pharmacist?

Required - Required.

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8. Question 8.

What is your job title?

Required - Required.

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9. Question 9.

Do you agree the privacy notice below?
Academic Health Science Networks North East and North Cumbria (AHSN NENC) and Health Education England respect your concerns about privacy. This Privacy Notice applies to the personal data that we collect and handle for the purposes of maintaining and providing PCN Pharmacy Professionals related information. For the purposes of this Privacy Notice, “personal data” means any information relating to an identified or identifiable individual.

Required - Required.

Yes

No