Ottawa Valley Physician Recruitment

THE UPPER OTTAWA VALLEY MEDICAL RECRUITMENT COMMITTEE
FAMILY PHYSICIAN WAIT FORM

Patients in the Upper Ottawa Valley Catchments Area
Includes: City of Pembroke, Townships of Laurentian Valley, North Algona/Wilberforce, Bonnechere Valley and the Algonquins of Pikwakanagan.

PATIENT NAME: First name, initial and last name.

YOUR SPOUSE/PARTNER: (only if without a family doctor).

ADDRESS:

E-Mail:

PHONE with area code:

Number of CHILDREN -
under 18; if over 18 years , please fill out a separate form.

NAME OF LAST FAMILY PHYSICIAN: (If you have a local family physician please do not register).

ADDRESS: City/Province.

Approximate DATE OF LAST VISIT:

ATTENTION - Residents of Petawawa please contact the Petawawa Centennial Family Health Centre to be part of the list.

PLEASE NOTE: These applications will be kept in confidence and made available to new physicians coming to the community and to other physicians taking new patients. If you have not been called it is an indication that no family physician is available at this time. PLEASE REFRAIN FROM CALLING the Upper Ottawa Valley Medical Recruitment Committee for information about your status on the wait list.

Waiver: Those involved in organizing this process cannot assure that a family physician accepts any patient. All those involved have been asked to work collaboratively to assist and support this process. However, it must be understood that being on the list does not guarantee a placement with a family physician.