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Hospital Forms

Your preceptor may have hospital privileges and require you to accompany him/her as part of your rotation.

Below is a list of rural placements and the documentation that is required. Please fill them out and return them promptly as they are needed at least 2 months before the start of your placement. If required, a good standing letter will automatically be sent by the Department of Family Medicine to the hospital.

It is the responsibility of the resident to make sure all necessary documentation has been completed and returned well in advance of the rotation. Failure to complete the form(s) may delay the start of the rotation.
City
Physician
Hospital
Documents

Alymer

Drs. D. Graham, M. Toth & R. Washburn

Family Medicine,
St. Thomas Elgin General

None

Blenheim

Drs. Martha Clendenning & James Wheeler

Family Medicine, Public General and St. Joseph's

Good Standing Letter Required.
Application Form & Guidelines pdf

Cambridge

Dr. Janet Samolczyk

Family Medicine, Cambridge Memorial

Good Standing Letter Required.

Chatham

Drs. Kate Bailey, David Hoffman, Sheri Roszell, Denys, Gamble, Milkovic, Munro, Sullivan, Sultan, Watterud.

Family Medicine, Chatham-Kent Health Alliance

Good Standing Letter Required.
Application Form & Guidelines pdf

Chatham

Drs. E. Haddad &
S. Murugappan

Surgery, Chatham-Kent Health Alliance

Good Standing Letter Required.
Application Form & Guidelines pdf

Chatham

Dr. Ian Johnson

Pediatrics, Chatham-Kent Health Alliance

Good Standing Letter Required.
Application Form & Guidelines pdf

Chatham

Drs. P. Letarte & Q. Tran

Medicine, Chatham-Kent Health Alliance

Good Standing Letter Required.
Application Form & Guidelines pdf

Chatham

Dr. Constance Nasello

OBS/Gyn, Chatham-Kent Health Alliance

Good Standing Letter Required.
Application Form & Guidelines pdf

Chatham

Dr. K. Narayanan

Anesthesia, Chatham-Kent Health Alliance

Good Standing Letter Required.
Application Form & Guidelines pdf

Clinton

Dr. Keith Hay

Family Medicine, Clinton Public

Good Standing Letter Required.
Registration Package pdf

Exeter Dr. Ken Milne Emergency Medicine, South Huron, Exeter
Good Standing Letter Required.
(Hospital forms will be emailed directly to resident)

Flesherton

Dr. Brian Power

Family Medicine, Grey Bruce Health Services, Markham Site

Good Standing Letter Required.

Goderich

Drs. Donald Neal & Samuel Appavoo

Family Medicine, Alexandra Marine & General

Good Standing Letter Required.
Application pdf

Grand Bend

Dr. Peter Englert

Family Medicine, South Huron, Exeter

Good Standing Letter Required.
(Hospital forms will be emailed directly to resident)

Hanover

Drs. Bruce Edington & Rochelle Dworkin

Family Medicine, Hanover & District

Good Standing Letter Required.

Ingersoll

Dr. Punkuj Chawla

Family Medicine, Alexandra

Good Standing Letter Required.
Confidentiality Agreement pdf
Privacy Policy pdf

Ingersoll

Dr. Joel Wohlgemut

Family Medicine, Alexandra

Good Standing Letter Required.
Confidentiality Agreement pdf
Privacy Policy pdf

Kitchener

Dr. Inderpal Saluja

Emergency Medicine, Grand River

Good Standing Letter Required.
Registration Form pdf
Confidentiality Agreement pdf
Privacy Awareness Training pdf

Kitchener

Drs. Heather Dixon, Alex Kolbasnik, Joseph Lee, Linda Lee, John Pefanis, John Yee

Family Medicine, Grand River

Good Standing Letter Required.
Registration Form pdf

Kitchener

Dr. Emma Wakim

OBS/Gyn, Grand River

Good Standing Letter Required.
Registration Form pdf
Confidentiality Agreement pdf
Privacy Awareness Training pdf
Resident Info Letter pdf
Map

Kitchener

Dr. Ahmed Jakda

Palliative Care, Grand River

Good Standing Letter Required.
Registration Form pdf
Confidentiality Agreement pdf
Privacy Awareness Training pdf

Leamington

Dr. R. Park

Family Medicine, Leamington District Memorial

Good Standing Letter Required.

Leamington

Dr. S. Horen

Geriatrics, Leamington District Memorial

Good Standing Letter Required.

Mt. Brydges

Drs. Copeland, Dalal, Osmun & Parr

Family Medicine, Strathroy Middlesex General

Good Standing Letter Required.
Registration Form pdf
Regional System Access Request Form pdf
LHSC Systems Access Agreement pdf
PACS Centricity Access Form pdf
Physician Confidentiality Agreement pdf

Newbury

Dr. Shelly Sharma

Family Medicine, Four Counties General

Good Standing Letter Required.
Registration Form pdf
Guidelines pdf

Owen Sound

Dr. Debbie Dyke

Family Medicine, Grey Bruce Health Services

Good Standing Letter Required.

Owen Sound

Dr. Caulley

Obs/gyn, Grey Bruce Health Services

Good Standing Letter Required.

Petrolia

Drs. John Butler , Enoch Daniel & Sue Mather

Family Medicine, Bluewater Health

Good Standing Letter Required.
Registration Form pdf
Medical Trainee Data pdf

Sarnia

Dr. Lori Kolano

Family Medicine, Bluewater Health

Good Standing Letter Required.
Registration Form pdf
Medical Trainee Data pdf
Dr. J. Grochowski Emergency Medicine, Bluewater Health
Dr. G. Jaychuk Psychiatry, Bluewater Health
Dr. M. Haddad ICU, Bluewater Health
Dr. G. Maddison Palliative Care, Bluewater Health

Dr. R. Saraf

Obs/Gyn,
Bluewater Health

Dr. P. Shetty Medicine, Bluewater Health
Dr. R. Suryavanshi General Surgery, Bluewater Health

Seaforth

Dr. Heather Percival

Family Medicine, Seaforth Medical Clinic

Good Standing Letter Required
Registration Package pdf

Southampton

Drs. Billings, Dyke, Suke & Wilson

Family Medicine, Grey Bruce Health Services

Good Standing Letter Required.

Stratford

Drs. T. Aitken &
D. Thompson

Dr. K. Blaine

Dr. K. LeFebvre

Dr. M. Mann

Dr. S. Narayan

Dr. P. Nascu
Family Medicine, Stratford General

Pediatrics, Stratford General
General Surgery, Stratford General
Emergency Medicine, Stratford General
Medicine, Stratford General
Obs Gynm Stratford General
Good Standing Letter Required.
Registration Package pdf

Strathroy

Drs. Neil Marshall, John Marcou, Philip Vandewalle, Daniel Leger & Tim MacDonald

Family Medicine, Strathroy Middlesex General

Good Standing Letter Required.
Registration Form pdf
Regional System Access Request Form pdf
LHSC Systems Access Agreement pdf
PACS Centricity Access Form pdf
Physician Confidentiality Agreement pdf

Strathroy

Dr. Daniel Grushka

Emergency Medicine, Strathroy Middlesex General

Good Standing Letter Required.
Registration Form pdf
Regional System Access Request Form pdf
LHSC Systems Access Agreement pdf
PACS Centricity Access Form pdf
Physician Confidentiality Agreement pdf

St. Marys

Drs. Tanya Thornton & Laurie Komorowski

Family Medicine, St. Marys Memorial

Good Standing Letter Required.
Registration Package pdf

St. Thomas

Dr. Timothy Burns

General Internal Medicine, St. Thomas Elgin General

Good Standing Letter Required.

St. Thomas

Dr. Rob Black

General Surgery, St. Thomas Elgin General

Good Standing Letter Required.

St. Thomas

Dr. Martin Hug

Hospitalist, St. Thomas Elgin General

Good Standing Letter Required.

St. Thomas

Dr. Suzanne Muise

Obs/Gyn, St. Thomas Elgin General

Good Standing Letter Required.

St. Thomas

Dr. Christian Paradis

Family Medicine, St. Thomas Elgin General

Good Standing Letter Required.

St. Thomas

Dr. Zahid Sardar

General Internal Medicine, St. Thomas Elgin General

Good Standing Letter Required.

St. Thomas

Dr. Kellie Scott

Family Medicine, St. Thomas Elgin General

Good Standing Letter Required.

Tavistock

Dr. Ken Hook

Family Medicine, Stratford General

Good Standing Letter Required.
Application pdf
By-Laws pdf
Confidentiality Agreement pdf
Acceptable Use of Computers pdf
Pre-placement Health Review Form pdf

Thorndale

Dr. Henry Chapeskie

Family Medicine, St. Joseph's Health Care - London

None

Walkerton

Dr. Paul McArthur

Family Medicine, South Bruce Grey Health Centre

Good Standing Letter Required.
(Hospital will send forms upon receipt of letter)

Wallaceburg

Dr. Dennis Atoe

Family Medicine, Chatham-Kent Health Alliance

Good Standing Letter Required.

Wellesley

Dr. Brian Finn

Family Medicine, Grand River

Good Standing Letter Required.
Registration Form pdf

West Lorne

Drs. Ghassan Abushawish, George Kim & Kevin Mardell

Family Medicine, Four Counties Health Services & St. Thomas Elgin General Hospital

Good Standing Letter Required.
Police Record Check

Windsor

Dr. Dale Ziter et al.

Windsor Regional & Hotel Dieu Grace

None

Wingham

Drs. Bonnie & Shaun Marshall

Family Medicine, Wingham & District

Good Standing Letter Required.
Application pdf
Infection Control Protocols pdf
Pledge of Confidentiality pdf

Woodstock

Dr. Jeffrey Nichols

Family Medicine, Woodstock General

Good Standing Letter Required.
Application Form pdf
Orientation Package pdf
CERNER pdf
AODA pdf
Code of Conduct pdf

Dr. Humphrey General Surgery, Woodstock General

Dr. Macdonald
Obs/Gyn, Woodstock General

Drs. Bennett & Urbantke
Emergency Medicine, Woodstock General
 
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