S-5, r. 5 - Organization and Management of Institutions Regulation

Schedule Disposition versions

2012-09-01

SCHEDULE VIII

(s. 85)

APPLICATION FORM FOR APPOINTMENT OF PHYSICIANS, DENTISTS, AND PHARMACISTS

1.0 Identification of candidate

1.1 Surname:

1.2 Surname at birth (if different from 1.1):

1.3 Given name:

1.4 Sex:

1.5 Citizenship:

1.6 Place of birth:

Date of birth:

1.7 Residence: Address:

Telephone:

1.8 Office: Address:

Telephone:

1.9 Social insurance number:

2.0 Education

2.1 Studies in medicine, dentistry, or pharmacy:

Discipline University Period Year degree received

Internship:

Period: Institution:

Residency:

Specialization Period Institution:

2.2 Other studies:

Discipline Period Degree

3.0 Licence to practice

Year Licence number

3.1 Québec

3.2 L.M.C.C.

3.3 Other (specify)

4.0 Certificate of specialization

Discipline Year of certification

4.1 Ordre professionnel des médecins du Québec

4.2 Royal College of Canada

4.3 Other (specify)

5.0 Publications

Attach list

6.0 Professional Experience

6.1 Medical experience

Period Institution Statut Privileges

6.2 Other professional experience

7.0 Persons able to provide references:

Surname and given name Address Telephone

7.1

7.2

7.3

8.0 Status and privileges requested

8.1 Status requested

active member honorary member

associate member consulting member

8.2 Privileges requested

physician

dentist

I wish to obtain the privileges enumerated in the list attached hereto.

9.0 Consent:

I authorize the persons responsible for the consideration of my application to obtain the required information from any establishment, physician, dentist, or pharmacist, provided that the confidential nature thereof be respected.

I authorize in particular the Secretary of the Ordre professionnel des médecins du Québec or his Assistant, the Secretary of the Ordre des dentistes du Québec or his Assistant, and the Secretary of the Ordre des pharmaciens du Québec or his Assistant, to release any information contained in my personal file that may be relevant to the consideration of my application.

This authorization is valid for the period of consideration of my application, according to the time limits prescribed in the Act respecting health services and social services for Cree Native persons (chapter S-5).

10.0 Liability insurance:

I attach hereto proof of possession of a professional civil liability insurance policy for myself and my heirs.

11.0 Declaration:

I declare that I am acquainted with the by-laws of the established in which I am requesting the abovementioned status and privileges. I undertake to respect them and to work within the limits of the health programmes adopted by the establishment.

Date:

Signature:

Witness:

Attached documents:

list of publications

list of privileges requested

proof of liability insurance

other documents

O.C. 1320-84, Sch. VIII; O.C. 375-88, s. 24.