Family Physician Recruitment Request Survey

1.Clinic Name and Information(Required.)

Clinic Name

Address

City/Town

Postal Code

2.Contact Name and Information(Required.)

Name

Email

Phone Number

3.Please complete the following information about the current physician resources in this clinic.(Required.)

Number of physicians working in clinic:

Equivalent full time (EFT) physicians working in the clinic:

Number of patients:

4.Please complete the following information about the current physician vacancies in this clinic.(Required.)

Number of physicians vacancies:

Equivalent full time (EFT) physician vacancies:

5.Are you currently recruiting recruiting physicians?
(Required.)

Yes

No