I am a Patient

var gform;gform||(document.addEventListener("gform_main_scripts_loaded",function(){gform.scriptsLoaded=!0}),document.addEventListener("gform/theme/scripts_loaded",function(){gform.themeScriptsLoaded=!0}),window.addEventListener("DOMContentLoaded",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>"function"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn("The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1."),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener("gform_main_scripts_loaded",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener("gform/theme/scripts_loaded",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener("DOMContentLoaded",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook("action",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook("filter",o,r,e,t)},doAction:function(o){gform.doHook("action",o,arguments)},applyFilters:function(o){return gform.doHook("filter",o,arguments)},removeAction:function(o,r){gform.removeHook("action",o,r)},removeFilter:function(o,r,e){gform.removeHook("filter",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+"_"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){"function"!=typeof(t=o.callable)&&(t=window[t]),"action"==r?t.apply(null,e):e[0]=t.apply(null,e)})),"filter"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});

"*" indicates required fields

1Patient Information
2Physician Information
3Main Concerns
4Other Information
5Finalize & Submit

Mailing Address*
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

I would like to receive correspondence from the College by:*
If you are filing a complaint against more than one physician, please complete a separate complaint form for each physician.

Description of the Incident

Please be as detailed as possible and provide information in paragraph form.
Please indicate the exact action(s) that the physician did OR did not do that is causing you to make this complaint. This summary is required to help the College better understand your concerns and process your complaint efficiently.

PLEASE LIST YOUR CONCERNS IN POINT FORM.

Additional Documents

If applicable, please list any additional information (i.e., written correspondence, audio recording, etc.) in your possession, that may be relevant to your complaint. The College's investigator will contact you if the additional information is necessary for their investigation.

Witnesses

List any people who may have information about this complaint. You are not required to have a witness to make a complaint. NOTE: Please ensure that each witness is aware that the College may contact them as part of the investigation of your complaint.

Follow-up Action

Describe any steps you may have taken to resolve your complaint.
I declare that I am the person identified as the "complainant" and that I am making a formal complaint against the physician named in this form.*

I declare that the information provided in this form is true and accurate to the best of my knowledge.*

I understand that the physician named in this complaint will be sent a copy of this form and all relevant information gathered during the investigation of my complaint.*

I understand that if my complaint leads to a hearing - or the Committee's decision is appealed to a court of law - information relating to my complaint must be disclosed and I may be called to testify as a witness.*

I understand that if I do not fully complete this form or participate in the investigation, my complaint may be dismissed for lack of information.*

I agree to engage in respectful communication with any individual involved in the College’s complaint process, including College staff and the respondent physician.*

Consent & Authorization

I, the undersigned, hereby consent and authorize the release of information contained in any health records about myself (including, but not limited to, hospital and doctor's office records, pharmaceutical records, and patient billing information) to the College of Physicians and Surgeons of Newfoundland and Labrador for the purpose of investigating my complaint against a physician.

I understand that the physician named in this complaint may access my personal health records for the sole purpose of responding to my complaint.*
MM slash DD slash YYYY
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
/* = 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { /* delay the scroll by 50 milliseconds to fix a bug in chrome */ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https://cpsnl.ca/wp-content/plugins/gravityforms/images/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_2').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger("gform_pre_post_render", [{ formId: "2", currentPage: "current_page", abort: function() { this.preventDefault(); } }]); if (event && event.defaultPrevented) { return; } const gformWrapperDiv = document.getElementById( "gform_wrapper_2" ); if ( gformWrapperDiv ) { const visibilitySpan = document.createElement( "span" ); visibilitySpan.id = "gform_visibility_test_2"; gformWrapperDiv.insertAdjacentElement( "afterend", visibilitySpan ); } const visibilityTestDiv = document.getElementById( "gform_visibility_test_2" ); let postRenderFired = false; function triggerPostRender() { if ( postRenderFired ) { return; } postRenderFired = true; jQuery( document ).trigger( 'gform_post_render', [2, current_page] ); gform.utils.trigger( { event: 'gform/postRender', native: false, data: { formId: 2, currentPage: current_page } } ); gform.utils.trigger( { event: 'gform/post_render', native: false, data: { formId: 2, currentPage: current_page } } ); if ( visibilityTestDiv ) { visibilityTestDiv.parentNode.removeChild( visibilityTestDiv ); } } function debounce( func, wait, immediate ) { var timeout; return function() { var context = this, args = arguments; var later = function() { timeout = null; if ( !immediate ) func.apply( context, args ); }; var callNow = immediate && !timeout; clearTimeout( timeout ); timeout = setTimeout( later, wait ); if ( callNow ) func.apply( context, args ); }; } const debouncedTriggerPostRender = debounce( function() { triggerPostRender(); }, 200 ); if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) { const observer = new MutationObserver( ( mutations ) => { mutations.forEach( ( mutation ) => { if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) { debouncedTriggerPostRender(); observer.disconnect(); } }); }); observer.observe( document.body, { attributes: true, childList: false, subtree: true, attributeFilter: [ 'style', 'class' ], }); } else { triggerPostRender(); } } );} ); /* ]]> */