{"id":2022,"date":"2024-05-10T06:56:28","date_gmt":"2024-05-10T06:56:28","guid":{"rendered":"https:\/\/remitystaffing.cumulative-projects.com\/?page_id=2022"},"modified":"2024-06-20T12:59:26","modified_gmt":"2024-06-20T12:59:26","slug":"doctors-reference-form","status":"publish","type":"page","link":"https:\/\/www.remitystaffing.com\/india\/doctors-reference-form\/","title":{"rendered":"Remity Staffing &#8211; Doctors Reference Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"2022\" class=\"elementor elementor-2022\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1337320 e-flex e-con-boxed e-con e-parent\" data-id=\"1337320\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-8c47842 e-con-full e-flex e-con e-child\" data-id=\"8c47842\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6020073 elementor-widget elementor-widget-heading\" data-id=\"6020073\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Remity Staffing \u2013 Doctors Reference Form <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d6ed0c3 e-flex e-con-boxed e-con e-parent\" data-id=\"d6ed0c3\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-d91fcb1 e-flex e-con-boxed e-con e-child\" data-id=\"d91fcb1\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6ece17a elementor-widget elementor-widget-shortcode\" data-id=\"6ece17a\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2024-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2024\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/india\/wp-json\/wp\/v2\/pages\/2022#wpcf7-f2024-o1\" method=\"post\" class=\"wpcf7-form init cf7skins cf7s-default\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2024\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2024-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:2024,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-288&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-doctors_reference&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Type&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;notice_dismissed_rollback-cf7-5.9.3&quot;:true,&quot;notice_dismissed_rollback-cf7-5.9.5&quot;:true}}\" \/>\n<\/div>\n<div class=\"uacf7-form-2024  \"><div class=\"formbox\">\n\t<div class=\"row\">\n\t\t<div class=\"col-full\">\n\t\t\t<h3>Remity Staffing - Reference Form (Doctors)<\/h3>\n\t\t\t<h6 class=\"mb-3\">Reference Form (Doctors)<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Date<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Full Name of Candidate<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"applicant_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"applicant_name\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>GMC Number<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"GMC_number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"GMC_number\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Position Aplied for<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"applied_for\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"applied_for\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Employed As<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employed\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employed\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Speciality<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"speciality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"speciality\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<div class=\"col-half\">\n\t\t\t\t<label>Grade<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"grade\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grade\" \/><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>From<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"from\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"from\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>To<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"to\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"to\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>NHS Trust<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"trust\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"trust\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Nature of Relationship with Applicant<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"nature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nature\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-3\">The above named doctor is presently working for you and as part of our recruitment process\n\t\t\t\twe would be greatful if you could complete the below tick box giving us a brief evaluation of their\n\t\t\t\tsuitability for the post by completing the enclosed reference form. Your opinion of character,\n\t\t\t\tabilities, health and any other comments that you think are relevant would be most helpful. Please be\n\t\t\t\tadvised that under the Data Protection Act, employees are allowed access to any information held on\n\t\t\t\ttheir personal files where any reference received would be located<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Investigation and Diagnosis<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"investigation\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"investigation\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"investigation\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"investigation\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"investigation\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Organisational Skills<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"skills\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"skills\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"skills\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"skills\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"skills\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Judgement & patient management<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"management\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"management\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"management\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"management\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"management\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Practicle Skill<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"practicle_skills\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"practicle_skills\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"practicle_skills\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"practicle_skills\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"practicle_skills\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-4\">Knowledge - Please tick appropriate box<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Basic Science<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"science\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"science\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"science\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"science\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"science\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Clinical<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"clinical\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"clinical\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"clinical\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"clinical\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"clinical\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-4\">Attitudes - Please tick appropriate box<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Reliability<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"reliability\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"reliability\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"reliability\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"reliability\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"reliability\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Time keeping<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"time_keeping\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"time_keeping\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"time_keeping\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"time_keeping\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"time_keeping\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-4\">Relationships - Please tick appropriate box<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Colleagues<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"colleagues\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"colleagues\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"colleagues\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"colleagues\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"colleagues\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Patients<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"patients\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"patients\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"patients\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"patients\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"patients\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-4\">Personal Qualities - Please tick appropriate box<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Appearance<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"appearance\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"appearance\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"appearance\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"appearance\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"appearance\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Integrity<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"integrity\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"integrity\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"integrity\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"integrity\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"integrity\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t<label>Manners<\/label>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"manners\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"manners\" value=\"Very Good\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Very Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"manners\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"manners\" value=\"Average\" \/><span class=\"wpcf7-list-item-label\">Average<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"manners\" value=\"Poor\" \/><span class=\"wpcf7-list-item-label\">Poor<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<label>Any other relevant Information<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"other_info\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" name=\"other_info\"><\/textarea><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<label> Has this person ever been the subject of disciplinary action or professional, Misconduct\n\t\t\t\tproceedings? please enter Yes or No (if yes please provide details)<span class=\"required\">*<\/span> <\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"disciplinary-action\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" name=\"disciplinary-action\"><\/textarea><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<label>Would you re-employee this person? (if No please provide details)<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"re-employee\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" name=\"re-employee\"><\/textarea><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-3\"> Referee's Details<\/h6>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Name<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"full_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"full_name\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Job Title<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"job_title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"job_title\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Organisation<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"organisation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"organisation\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Contact Number<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"contact_num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"contact_num\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<label>Email<span class=\"required\">*<\/span><\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<div class=\"formgroup sing\">\n\t\t\t\t\t<label>Signature<span class=\"required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_doctors_reference\" name=\"doctors_reference\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#FAFAFA\" width=\"460\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap doctors_reference\">\n\t\t\t\t<input class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-requiredwpcf7-validates-as-signature form-controldscf7-signature\" value=\"\" type=\"hidden\" name=\"doctors_reference\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"doctors_reference-attachment\" class=\"wpcf7_input_doctors_reference_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"doctors_reference-inline\" class=\"wpcf7_input_doctors_reference_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t<div class=\"radio_checkbox\">\n\t\t\t\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-doctors_reference\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-doctors_reference\" value=\"Draw\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Draw<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-doctors_reference\" value=\"Type\" \/><span class=\"wpcf7-list-item-label\">Type<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<span data-id=\"group-288\" data-orig_data_id=\"group-288\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t<input type=\"text\" name=\"sign_text form-control\" id=\"sign_text\" \n\t\t\t\t\t\t\t\t oninput=\"changeFont(this,'digital_signature-pad_doctors_reference')\">\n\t\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-half\">\n\t\t\t<input class=\"wpcf7-form-control wpcf7-submit has-spinner submit_button\" type=\"submit\" value=\"Send\" \/>\n\t\t<\/div>\n\t<\/div>\n<\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Remity Staffing \u2013 Doctors Reference 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