Have the medical recommendations been signed on or before the date of the Yes No application? If the doctors making the recommendations examined the patient separately has the ☐ Yes No N/A examination taken place within no more than 5 clear days of each other? Where a joint medical recommendation has been used is the date of the examination by ☐ Yes No N/A both doctors the same? Is the name and address of the patient Yes No correct and correctly spelt on all of the papers? Has the applicant and both doctors given Yes No their full name and address? Have the doctors completing medical recommendations clearly indicated whether Yes No or not they are S12 approved and/or had previous acquaintance with the patient? Is at least one of the medical recommendations provided by a Section 12 Yes No approved doctor? Where neither of the doctors had previous acquaintance with the patient before making their recommendations has the applicant recorded (on form A5 or A6) the ☐ Yes No N/A reason why this is the case? Yes No Have all the necessary deletions been made? Yes No Does the application or medical recommendations contain any omissions? Please complete following scrutiny Name of person Date of scrutiny Signature carrying out scrutiny NOTES (The Scrutiny Administrator should record any remedial action taken including outcome) Additional Processes (Admin) MHL Lead
Have the medical recommendations been signed on or before the date of the application? Yes No If the doctors making the recommendations examined the patient separately has the examination taken place within no more than 5 clear days of each other? Yes No ☐ N/A Where a joint medical recommendation has been used is the date of the examination by both doctors the same? Yes No ☐ N/A Is the name and address of the patient correct and correctly spelt on all of the papers? Yes No Has the applicant and both doctors given their full name and address? Yes No Have the doctors completing medical recommendations clearly indicated whether or not they are S12 approved and/or had previous acquaintance with the patient? Yes No Is at least one of the medical recommendations provided by a Section 12 approved doctor? Yes No Where neither of the doctors had previous acquaintance with the patient before making their recommendations has the applicant recorded (on form A5 or A6) the reason why this is the case? Yes No ☐ N/A Have all the necessary deletions been made? Yes No Does the application or medical recommendations contain any omissions? Yes No Please complete following scrutiny Name of person carrying out scrutiny Date of scrutiny Signature NOTES (The Scrutiny Administrator should record any remedial action taken including outcome) Additional Processes (Admin) MHL Lead
MHA-PGN-08-App10-C-list-Sec3-V01-Iss1-IssJun-18.docx