APPLICATION FORM FOR PROSPECTIVE OBSERVERS
Please complete and return via email (observers@moorfields.nhs.uk) direct line(+44
(0)20 7566 2428) or post, Postgraduate Medical Education Centre, Moorfields Eye
Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, United
Kingdom.
Please complete all areas in block capitals
Surname:………………………… First name: …………….…………………….
Title:
Dr / Mr / Miss / Mrs
Nationality: ……………………
Date of birth: …………………………….
Postal address for correspondence (including postal code & country):
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Email address: ……………………………………………………………………………..
Daytime telephone number including codes:
…………………………………………………………………………………………………..
Medical school where qualified:
…………………………………………………………..
Present appointment / grade:
…………………………………………………….
Hospital / NHS Trust and country:
…………………………………………………………………………………………………
…..
Please select the service or services you wish to visit:
Sub-specialty
Adnexal Service
Number of weeks required
Cataract Service
Cornea & External Diseases Service
Glaucoma Service (2 WEEKS MAXIMUM)
Medical Retina Service (2 WEEKS MAXIMUM)
Neuro-ophthalmology Service
Strabismus & Paediatrics Service
Vitreoretinal Service
First possible arrival date: ……………………………………………………
I must leave Moorfields no later than Friday: …………………………………
Ophthalmic observers are accepted for a maximum stay of 2 months.
As there are a number of public holidays in the UK throughout the year, we recommend that
you check all dates to ensure your booking does not coincide with these.
We work on a ‘first come first served’ basis so please give as much notice as possible when
you make your request. It is advisable to apply at least 6 – 9 months in advance of the date
you wish to attend. All bookings are from Monday to Friday.
FEES
The Trust charges a fee of £150 per week (Monday to Friday) which must be paid in
advance and full fee must be paid to secure the place. This fee is non-refundable.
We only accept payment in pounds sterling via;
 Debit or credit card
 Overseas bankers’ cheque drawn on a UK bank
 Personal cheque for holders of a UK bank account
Cheques must be made out to ‘Moorfields Eye Hospital NHS Foundation Trust’.
Payment must NOT be made by bank transfer.
Your observership period can only be confirmed upon receipt of your full payment.
As soon as your visit has been agreed you will receive a formal letter of confirmation
including details of how to find the hospital and where to go on your first day.
PLEASE ENSURE YOU SIGN AND DATE YOUR APPLICATION HERE:
SIGNED: …….. .………
DATE…………………………..