Reference Request

*CONSULTANT (REFEREE) NAME AND ADDRESS DETAILS HERE*

Date

Dear Doctor,

Reference Request for: Dr Jahangir Alam

The Doctor mentioned below has registered with Medacs Healthcare to work in the UK and has quoted you
as a referee.

We would be grateful if you would reply to the following questions regarding this applicant and provide in
confidence any information which you are able to comment on regarding his/her character and suitability to
perform the role and associated duties of the position applied for.

Applicant name

Organisation
Practice/Hospital where the Worker was/is employed
Dates of employment
(DD MMM YYYY – DD MMM YYYY)
Grade & Skill
Grade & Skill covered in above position
commentUnable to

Satisfactory

Very Good
* Please ü as appropriate

Excellent
Good
Poor

(Please provide additional comments in support of the statements

made in the space provided on the next page)

Clinical skills demonstrated in line with the requirements of the

position
Relationships with patients, other healthcare workers and the public
Timekeeping and management of workload
Patient records and other record management
Reliability
Communication skills
Supervisory skills
Organisational ability
Sickness/Absence record
How would you rate the applicant’s honesty and discretion

* Mandatory Information – Please ensure all asterisked items are completed

Medacs Healthcare
Reference Request

Additional comments in support of the statements made

How long did the named applicant work for/with you or under your supervision and in what capacity?
i.e. clinical position/grade and specialty

*Main details and responsibilities: (please use the additional information section if required)

Do you know of any factors concerning the named applicant which might cause his/her fitness for
employment or reasons why the named applicant should not work in a clinical environment?
If so please provide details below.

Please provide any further information relevant to the supply of the candidate as a Locum,
e.g. which grade you consider the applicant best suited for.

* Mandatory Information – Please ensure all asterisked items are completed

Medacs Healthcare
Reference Request

Reference request completed for Medacs Healthcare by

*Referee Job Title
Referee Name
Medacs Healthcare is unable to *Date
*Signature accept unsigned references,
please sign before returning
*Tel. No.
Email Address
To confirm this reference as valid, please ensure the form is physically signed and
*Proof of returned, either by scanning and emailing or faxing. Please also provide a company
Organisation stamp or counter-signed compliment slip; the references could alternatively be printed
on headed paper.

Additional
Information

Please scan & email back to Kate.Clarke@medacs.com

To confirm this reference as valid, please ensure the form is physically signed and returned,
either by scanning and emailing or faxing. Please also provide a company stamp or counter-
signed compliment slip; the references could alternatively be printed on headed paper.

Medacs Healthcare

Email: Kate.Clarke@Medacs.com

Tel: 0044 (0)203 096 4590

* Mandatory Information – Please ensure all asterisked items are completed

Medacs Healthcare