Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Department *

Select one or more of the following:

Anaesthesia

Emergency Medicine

Family Practice

Geriatrics

Hospitalist

Internal Medicine

Internal Medicine - Critical Care

Internal Medicine - Gastroenterology

Internal Medicine - General Internal Medicine

Internal Medicine - Respirology

Paediatrics

Palliative Care

Psychiatry

Psychiatry - General Psychiatry

Psychiatry - Inpatient

Psychiatry. - Outpatient

Radiology

Surgery

Surgery - General Surgery

Surgery - Obstetrics and gynaecology

Surgery - Otolaryngology (ENT)

Surgery - Urology

Confirmation *

I hereby confirm that the above information about myself is correct and grant Admin to publish it on the internal directory of Peace Arch Hospital Medical Staff Association's website.

I agree