Physician Questionnaire

The purpose of this questionnaire is to ensure the accuracy of the information that the College has on file for you and to assist us in communicating with you in an efficient manner in relation to this allegation. You are required to complete this questionnaire within 7 days.

If you have questions, please contact the College’s Professional Conduct Coordinator at 709-778-4280 or by email, complaints@cpsnl.ca

Contact Information

For the purposes of receiving communication from the College relating to this allegation.

Full Name(Required)

Email(Required)

Daytime Telephone Number(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is there an additional person (e.g., lawyer, administrative assistant, etc.) who we can communicate with regarding this allegation?(Required)

Yes

If yes, please provide their name and contact information

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Licence and Privileges

Do you hold a licence to practice medicine in another province?(Required)

Yes

If yes, where?

Do you hold a licence to practice medicine in another country/jurisdiction?(Required)

Yes

If yes, where?

Do you hold active privileges with NL Health Services?(Required)

Yes

If yes, at what location(s)?