Applicant Details
Name:
*
First Name
Last Name
Occupation:
*
Please Select
Consultant Gynaecologist
Consultant Urogynaecologist
Subspecialist in Urogynaecology
Other (please specify)
If Other Please Specify
Employing Trust:
*
Email
*
example@example.com
BSUG or BAUS Member:
*
BSUG
BAUS
No (This scheme is for BSUG or BAUS members only)
Previous Urogynaecology Training
*
Please Select
Subspecialty training
ATSM
SSM
Special interest training
Nil formal
Other (Please specify)
If Other Please Specify
Please select the procedure you are registering to learn under the mentorship scheme
Colposuspension (open)
Colposuspension (laparoscopic)
Autologous fascial sling
Sacrocolpopexy – (open)
Sacrocolpopexy – (laparoscopic)
Has your Medical Director (or equivalent) approved the training?:
*
Yes
No (if no this should be sought before training starts
I confirm I am a current user of the BSUG audit database
*
Yes
Mentor Details
Name
*
First Name
Last Name
Occupation:
*
Please Select
Consultant Gynaecologist
Consultant Urogynaecologist
Consultant Urologist
Other (please specify)
If Other Please Specify
Employing Trust:
*
Email
*
example@example.com
BSUG or BAUS Member:
*
Yes
No
Has the mentor agreed to undertake the training?:
*
Yes
No (if no this should be sought before training starts
Submit
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