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Professional Indemnity For Dental Nurses

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Renewal Details
Renewal Date	Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2009 2010 2011	Renewal Premium
Customer Details
Clients Name
Telephone Number		Email
Home Building Name/Number		Post Code
Surgery or Practice Address
Date Of Birth
GDC Registration Number		Year of Qualification
Which professional organisations are you a member of		Details of qualifications and dates achieved
Details of any refresher / CPD training of procedures in the last 12 months
Claims Experience
Have you made any claims within the last 3 years	Select Yes No	Number of claims made	Select 1 2 3 4 5+
If yes please provide details of claims below
Claim Type	Date Of Claim	Payments made
Any Criminal convictions not spent under the Rehabilitation of Offenders Act	Select Yes No	If yes provide details
Do you understand and carry out effective Health & Safety procedures?	Select Yes No	Do you practice safe infection control procedures?	Select Yes No
Are you trained in CPR, medical emergencies and common dental emergencies?	Select Yes No	Do you understand and carry out effective ionising radiation procedures?	Select Yes No
Do you carry out personal development planning?	Select Yes No	Can you show evidence of: - Assisting the dentist and basic safety skills	Select Yes No
- Communication and working with a team.	Select Yes No	- Ethics, confidentiality and equal opportunities.	Select Yes No
- Working with patients including giving advice.	Select Yes No	- Customer service skills, complaints handling and coping in difficult situations	Select Yes No
		If No to any of above; please provide details please
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