Local representative advice form

My details

Representative name handling case *

Rep BMA ID or GMC number *

Member Name (Record all contacts if more that one involved) *

Member BMA ID or GMC number *

BMA Region *

Employer *

Employer Site *

Case status *

Follow up date *

Next action *

Advice sought from BMA staff? *

Yes

No

Name of staff *

Category of advice *

Description of query and answer given *

Please upload any relevant documents

Do legal deadlines or other deadlines apply? *

Yes

No

Please seek guidance from BMA staff immediately

Applicable deadline dates *

Preferred email address of member *

Preferred phone number of member *

Branch of practice of member *

Grade of member *

Specialty of member - if known