Undergraduate Application Form

Personal Details


Home Address

Correspondence Address (If different)






Elective Placement Details

Please note: It is the student’s responsibility to contact potential clinical supervisors within the Trust directly to enquire whether they are willing to act in this role. Due to the number of enquiries submitted each year, the Medical and Dental Education Department cannot do this on their behalf.

Search our list of consultants (opens in new browser window)

Have you confirmed this placement with the consultant?

If you haven’t arranged your placement with the consultant yourself it will not go ahead.

Applicant Certification 

I have read and understood all the application materials and conditions for visiting electives at the Trust. I understand that acceptance of an undergraduate elective place is on the understanding that I will abide by all regulations in place at the Trust and all the conditions set out on the Trust website.

By ticking the box below:

  • I confirm that all information given in this application is accurate and true.
  • I understand that the Trust has a responsibility to ensure the confidentiality and dignity of its patients, their carers and any other third parties in accordance with the Data Protection Act (1998) and that I have an obligation to uphold patients’ privacy.
  • I agree that I will not access, pass on or discuss personal information about a patient or any other person unless there is a specific need to do so that is directly related to their clinical care, and only under instruction by my Clinical Supervisor.
  • I understand that what I experience in the clinical environment is privileged, and that failure to maintain this confidentiality may lead to prosecution should the Trust become involved in a case of litigation instigated by a patient, carer or third party.

Please download the four forms below under related content.

The Health Form, Academic Verification and Applicant Certification are to be completed by the student and the Supervisor Agreement form buy the consultant – all the forms should be emailed to medical.electives@pat.nhs.uk.  Your application cannot be processed without the completed forms.

Mandatory forms to be completed and sent with your application are below