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… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): … 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency...
… 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): … 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): … CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency C...
… 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): … 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency...
… 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … 1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
1 CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency Contact Person: Contacts P...
… CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family … CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated …
CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: Phone: Email: Emergency Contact Person: Contacts Phone: Prim...
… FOR VISITING ELECTIVES Revised 20190322 Page 1 of 4 (MUST Provide Proof) Past LHSC/St. Joseph’s Record: Yes No Anticipated Start Date of … FOR VISITING ELECTIVES Revised 20190322 Page 1 of 4 (MUST Provide Proof) Past LHSC/St. Joseph’s Record: Yes No Anticipated Start …
GUIDELINES FOR COMPLETION OF CITY-WIDE HEALTH SCREEN FOR VISITING ELECTIVES Revised 20190322 Page 1 of 4 (MUST Provide Proof) Past LHSC/St. Josephs Record: Yes No Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Na...
… 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): … 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): First Name: Last Name: Gender: Date of Birth (YYYY/MM/DD): Family Physician: CPSO #: Phone: Email: Emergency...
… 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): Last Name: First Name: Gender: Date of Birth (YYYY/MM/DD): … 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): Last Name: First Name: Gender: Date of Birth (YYYY/MM/DD): Primary Care Provider/Physician: CPSO #: Phone: E...
… 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): Last Name: First Name: Gender: Date of Birth (YYYY/MM/DD): … 1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of …
1 CITY-WIDE HEALTH SCREEN FOR PROFESSIONAL STAFF/RESIDENTS/CLINICAL FELLOWS Anticipated Start Date of Clinical Placement (YYYY/MM/DD): Anticipated End Date of Clinical Placement (YYYY/MM/DD): Last Name: First Name: Gender: Date of Birth (YYYY/MM/DD): Primary Care Provider/Physician: CPSO #: Phone: E...
Dr. s copy Western Schulich School of Medicine & Dentistrys copy Department of s copy Medical Affairs copy THIS LETTER OF OFFER IS ONLY TO BE ISSUED AFTER CONFIRMATION OF THREE SATISFACTORY REFERENCES FOR THE CANDIDATE. Dear Dr.
Dr. s copy Western Schulich School of Medicine & Dentistrys copy Department of s copy Medical Affairs copy THIS LETTER OF OFFER IS ONLY TO BE ISSUED AFTER CONFIRMATION OF THREE SATISFACTORY REFERENCES FOR THE CANDIDATE. Dear Dr.
Dr. s copy Western Schulich School of Medicine & Dentistrys copy Department of s copy Medical Affairs copy THIS LETTER OF OFFER IS ONLY TO BE ISSUED AFTER CONFIRMATION OF THREE SATISFACTORY REFERENCES FOR THE CANDIDATE. Dear Dr.