Evidence Of Internship Form

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Evidence of internship form
Section A
I confirm that
Doctor’s name
Doctor’s GMC reference number
has been engaged in a resident medical capacity in one or more approved hospitals or approved institutions
between:
Start date
D D M M Y Y Y Y
Finish date
D D M M Y Y Y Y
and that during that period satisfactory service has been rendered for the following periods of employment:
Rotation
Surgery or
Start date
Finish date
Number of
Medicine (please
weeks
tick)
Surgery
Example: Obstetrics
13 weeks
0
1
0
1
2
0
0
8
3
0
0
3
2
0
0
8
& Gynaecology
Medicine
Surgery
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Medicine
Surgery
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Medicine
Surgery
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Medicine
Surgery
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Medicine

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