Registered medical practitioner notification form template

Health Protection (Notification) Regulations 2010: notification to the proper officer of the local authority
Registered Medical Practitioner reporting the disease
Name
Address
Address
Post code
Contact number
Date of notification
Notifiable disease
Disease, infection or contamination
Date of onset of symptoms
Date of diagnosis
Date of death (if patient died)
Index case details
First name
Surname
Gender (M/F)
DOB
Ethnicity
NHS number
Home address
Home address
Post code
Current residence if not home address
Current residence if not home address
Post code
Contact number
Occupation (if relevant)
Work/education address (if relevant)
Work/education address (if relevant)
Post code
Contact number
Overseas travel, if relevant (Destinations & dates)