Medical Reference	

Medical reference for an individual provider of a regulated service	
Full Name		
Address		

Post code		
Telephone number		
E-mail		
Date of Birth (dd/mm/yyyy)		
Place of birth		
Former names		
Any other previous surname		
Type of service 
(ie. care home service, domiciliary support service)		

Important: 
We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://www.careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.

GP Section 
(to be completed by GP)	
Name		
Surgery address		
		
Surgery postcode		
Note to GP	
The individual named overleaf has applied to register as the provider of a service regulated by us. This holds certain legal duties, such as ;
•	overseeing the management of the regulated service;
•	ensuring effective oversight of the regulated service, including the adequacy of resources; 
•	reviewing and improving the quality of the service; 
•	and promoting a culture of openness and accountability; and
•	overall accountability for the standard of care and support .	
It is my opinion that after reading the medical notes of: Name of applicant

(please tick appropriate box below*)
*please do not write any sensitive information on this form as it will be uploaded as part of an application, if you cannot tick the boxes below, we will contact you for further information 	
There is nothing in the individual’s medical records which would impact on their ability to comply with the duties set out above		
		
The individual has a condition or disability (including mental disability) which may affect their ability to comply with the duties set out above		

GP Signature	Date	

		
Surgery stamp**

**medical reference is invalid without the surgery stamp