Registration Form

Outpatients Clinic Build Form

Please ensure before you complete this form that you have confirmed room availability and Nursing Support is available with the Outpatients Manager via email. Failure to do this may result in your request being rejected.

Is this request a New Build or a Template Change?* Date email confirmation of room availability received:*

Room confirmed by [Room Booking Form Reference Number]*

Has Nursing Support been agreed?*

Enter your Email Address*

Select Specialty*

Name of Clinician/Nurse/Associated Health Practioner*

Date this change is for or start date for new clinic*

Is this a NEW clinic build? Has this been approved at the Activity Recording Panel (ARP)?*

Enter ARP Approved Number

Clinic Location/ Site*

Clinic session AM/PM*

Please select visit type(s) for this clinic:*

	NEW F2F
	FUP F2F
	NEW TEL
	FUP TEL
	NEW e-Clinic
	FUP e-clinic
	NEW VIRTUAL
	2WW NEW
	2WW TELEPHONE

All Templates for new appointments will be attached to eRS. If this template is exempt please select reason why:*

Operational hours - PLEASE CLICK ON THE DAY OR DAYS THAT THIS CHANGE IS FOR

DAY	MON	TUE	WED	THU	FRI	SAT	SUN
AM
PM

How many patient per time slot? What visit type per time slot - f2f/tel/e-clinic? Also please state new or FUP in the tables below

AM SESSION	NEW	FUP
Start Time
Appointment Time Duration
Clinic Finish Time

Additional Information

PM SESSION	NEW	FUP
Start Time
Appointment Time Duration
Clinic Finish Time

Additional Information

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