Download application - Annapolis Valley Health

ANNAPOLIS VALLEY DISTRICT HEALTH AUTHORITY
PRIVILEGES APPLICATION FORM
FOR RESIDENTS & MEDICAL STUDENTS
Submit to:
Dr. Lynne Harrigan, VP – Medicine
c/o Angie Davidson, Administrative Assistant, AVDHA
Annapolis Valley District Health Authority
15 Chipman Drive
Kentville, NS B4N 3V7
FAX: 902 538 3432
Submitted by:
Date: ________________________
Residents and Medical Students applying to the Annapolis Valley
District Health Authority must arrange for a letter from their university
program director confirming their status in their program and proof of
medical insurance coverage during their rotation at the site within the
AVDHA to be sent to the above address. Residents must provide proof of
current registration with the N.S. College of Physicians & Surgeons
(educational license).
NB:
In making application for appointment to the Medical Staff of the Annapolis Valley District
Health Authority, I agree to abide by the By-Laws of the District Health Authority, a copy of
which I have received and read, and by such rules and regulations as may from time to time
be enacted. I agree to abide and be governed by the Code of Ethics as adopted by the
Canadian Medical Association and the Royal College of Physicians and Surgeons. It is also
agreed that the appropriate authorities of the Annapolis Valley District Health Authority may
contact any person or organization named in this application to verify the correctness of
information and solicit such further information from these or other sources as may be
deemed necessary in consideration of this application.
Signature of Applicant
While all responses are considered material to your application, they are not necessarily the
sole criteria for appointment of hospital privileges by the Board of the District Health
Authority.
(2)
(NB: Please Type or Print)
APPLICATION FOR RESIDENTS AND MEDICAL STUDENTS
ANNAPOLIS VALLEY DISTRICT HEALTH AUTHORITY
A.
1. Name in full ___________________________
Date ________________
Last
First
Middle
2. Telephone
_________________Email: ____________________________
Residence Address
_____________________________________________
________
3. Date of Birth
________________
_____________________
4. Medical Education:
College or University
________________
Degree
Date of Graduation ___________
Other Degrees
________________
5. Educational License: (Please attach copy of current License)
CPSNS Number: _____________________
Prov.
Year _________
6. Have you ever been convicted of a criminal offence either under the Criminal
Code of Canada or in another Jurisdiction?  Yes
 No
(If yes, give details.)
______
The following questions are for Post-graduate Students only:
7.
Any gaps in chronological order in this section must be explained.
(a) Internship:
Hospital
Years
Hospital
Years
(b) Certification Canadian College of Family Practice
University
Specialty
Year
Period
(3)
The applicant hereby applies for either:
Resident Privileges
(Please check one of the above)
or Medical Student Privileges
_________
Name of Preceptor (Member of AVDHA Medical Staff)
In the following list, underline Department/Division of the above named preceptor:
Anaesthesia, Radiology, Pathology, Emergency, Family Practice, Medicine,
Obstetrics/Gynaecology, Paediatrics, Psychiatry, Surgery
Dates of requested Clinical Experience at AVDHA site:
From
__________
To
________
Privileges requested at the following facility (ies): - Please check appropriate
facility(ies) below:
Eastern Kings Memorial Community Health Centre
(Wolfville)
Valley Regional Hospital
(Kentville)
Western Kings Memorial Health Centre
(Berwick)
Soldiers Memorial Hospital
(Middleton)
Annapolis Community Health Centre
(Annapolis Royal)
Signature of Applicant
The above request is confirmed by:
Signature of Above Named Preceptor
Date