Clinical Placement request

Name (required)

Contact number (required)

Email (required)

Next of kin contact number (required)

Current role/occupation (required)

PVG Membership (required)

Current employer (required)

Which service do you wish to visit? (Please select as many as you like) (required)

In-patient unitPhysiotherapyOccupational TherapySocial WorkCounsellingMedical TeamLiving Well HubSpecialist Palliative Care Community Nursing

How long would you like to visit us on placement? (required)

When would you like your placement to begin? (required)

Please specify your key learning objectives

How is this linked to your current role and professional development?