PEME PROGRAMME CLINIC INFORMATION FORM
PEME PROGRAMME CLINIC INFORMATION FORM Clinic Name: _____________________________________________________________________________________ Clinic full address: _________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ Hours of operation: _________________________________________________________________________________ Tel:______________________________________________ Fax: ____________________________________________ Out-of-hours contact: ______________________________________________________________________________ Email: ____________________________________________________________________________________________ Alternative email: ___________________________________________________________________________________ Doctors name(s): __________________________________________________________________________________ __________________________________________________________________________________________________ Branch name (if any): _______________________________________________________________________________ Address: _________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Tel:______________________________________________ Fax: ____________________________________________ Out-of-hours contact: ______________________________________________________________________________ Email: ___________________________________________________________________________________________ Alternative email: ___________________________________________________________________________________ Doctors name(s): __________________________________________________________________________________ __________________________________________________________________________________________________ Branch Manager: __________________________________________________________________________________ Billing via Feesable: Yes No Completing PEME web records part A and B: Yes No Flag state approval: ________________________________________________________________________________ Other P&I Club approval: ___________________________________________________________________________ Standard PEME cost (USD): _______________________________________________________________________ When complete, please email this form to the UK P&I Club PEME team at [email protected] PEME PROGRAMME CLINIC INFORMATION FORM Additional details if required: _________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ When complete, please email this form to the UK P&I Club PEME team at [email protected]
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