Set up a Mandate

The work of the LDC is funded purely by voluntary mandates from GDPs in the area.
To this end, we ask that all GDPs in the area set up a mandate for £3 per calendar month paid from your NHS schedule.

If you have not already set up a mandate, please either fill out the form below or download and print off a paper version of this mandate which can be posted or emailed to the LDC Secretary, whose address is on the mandate form.

To: Highland Health Board
I, the undersigned

Full name (As appears on GDC register)

First Name

Surname

Email

Address (as registered with the GDC)

Street Address

Address Line 2 (optional)

Address Line 3 (optional)

Town / City

Postal Code

Having entered into a written agreement with Highland Health Board (hereinafter called “the Board”) whereby I have undertaken the treatment of persons under the National Health Service Acts, do hereby authorise and request the Practitioner Services, NHS National Services Scotland/Common Services Agency (hereiniafter called the “Agency”) (unless and until this authority and request shall to be revoked) to deduct from the sums due to me at the end of each month £3.00 of my remuneration from the Agency as may from time to time be resolved upon and requisitioned by Highland Local Dental Committee (General Practitioners) (hereinafter referred to as “the Committee”). This mandate cancels any previous Mandate granted by me to the Agency.

I hereby authorise and request the Agency to pay all such sums as may be deducted as aforesaid to the Treasurer for the time being of the Committee (or as the Treasurer may direct), to be applied in meeting the expenses of the Committee and in making such other payments as may be resolved upon by the Committee, providing always that the receipt of the Treasurer or other authorised official of the Committee shall, under all circumstances and in any event, be a full and sufficient discharge to the Agency for all sums paid by the Agency as aforesaid; and the Agency shall not in any way be concerned with or have any authority to enquire as to the application of the sums so paid; and I agree to indemnify the Agency of all claims in connection with the deduction of the said sums or anything done or omitted to be done under the authority herein contained.

I consent to my personal data being shared to the Agency in order for the purpose of executing this mandate.

I confirm that I am authorising you to instruct PSD to take a levy from my NHS Schedule each month.

GDC Number

Highland Health Board List Number

Yes, I have read the terms and conditions and I understand you will take a levy form my NHS Schedule each month

Please sign below using mouse or touchpad.