3. Would other Specialists in the practice / department wish to be Yes / No involved in training? If so, please list their names and qualifications/date of entry onto Specialist List: a) Name: Full / Part time Partner / Expense sharing Partner / Associate / Consultant / other Qualifications/Date of entry onto Specialist List: b) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List c) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List: d) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List: 4. Do you have sufficient space, nursing support and patients to Yes / No provide a student Orthodontic Therapist with 7-8 sessions of supervised clinical training per week? 5. How many fully operational chairs are there in the practice or department? 6. How many surgeries are there in the practice or department? 7. Will the student Orthodontic Therapist have their own designated Yes / No chair? 8. Will a GDC registered nurse work with the student Orthodontic Yes/ No Therapist? 9. Will the student Orthodontic Therapist work between two Yes / No practices or departments? If so, please provide details. 10. Please complete the Outline of Work Placement Form in conjunction with your proposed student and submit this with this application form. 11. What percentage of patients in the practice/department are likely % to be NHS? 12. What percentage of your clinical practice are: < 18 years of age % > 18 years of age % Routine orthodontic treatments % Multidisciplinary cases %
3. Would other Specialists in the practice / department wish to be involved in training? Yes / No If so, please list their names and qualifications/date of entry onto Specialist List: a) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List: b) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List c) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List: d) Name: Partner / Expense sharing Partner / Associate / Consultant / other Full / Part time Qualifications/Date of entry onto Specialist List: 4. Do you have sufficient space, nursing support and patients to provide a student Orthodontic Therapist with 7-8 sessions of supervised clinical training per week? Yes / No 5. How many fully operational chairs are there in the practice or department? 6. How many surgeries are there in the practice or department? 7. Will the student Orthodontic Therapist have their own designated chair? Yes / No 8. Will a GDC registered nurse work with the student Orthodontic Therapist? Yes/ No 9. Will the student Orthodontic Therapist work between two practices or departments? If so, please provide details. Yes / No 10. Please complete the Outline of Work Placement Form in conjunction with your proposed student and submit this with this application form. 11. What percentage of patients in the practice/department are likely to be NHS? % 12. What percentage of your clinical practice are: < 18 years of age > 18 years of age Routine orthodontic treatments Multidisciplinary cases % % % %
c__ot_trainer_application_form_2019.docx