Membership Application Form

All of the information on this form will be kept private.

Divisions of Family Practice are groups of physicians organized at the local level who work to address common health care goals.

NOTE: This form is NOT for patients looking for a Family Doctor. Please proceed to our Find a Family Doctor Program link on our website's main page.

I am a*

new family physician joining a clinic in the Central Okanagannew family physician locumresident seeking an associate member accountOther

Member Benefits you would like to receive (select all that apply)*

Up to date - free for membersPathways user keyMonthly Member newsletter - Divisional DigestMonthly Locum newsletter

Name*

First NameLast Name

Email*

example@example.com

MSP Billing Number :*

CFPC Number:*

Name of the clinic you will be joining:*

Your start date at the clinic*

Clinic Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code

Clinic Phone Number*

Please enter a valid phone number.

Clinic Fax Phone Number*

Please enter a valid phone number.

Cell Phone Number*

Please enter a valid phone number.

Are you currently part of another Division of Family Practice*

YesNo

If yes, which Division(s) are you part of?*

Did you want Central Okanagan Division to be your Primary or Secondary Division?*

Primary (I will be in Kelowna more than 50% of the time OR my home address is located within Central Okanagan)Secondary (I will be in Kelowna less than 50% of the time OR my home address is located outside of Central Okanagan)

Will you be accepting any LTC patients or covering for a colleague who has LTC patients at your clinic:*

YesNoUnsure, need to confirm with clinic call group

Are you interested in taking on any patients from our Patient Attachment Waitlist?*

YesNoneed more information

AGREEMENT AND SIGNATURE: I agree that information gained as a member of the Central Okanagan Divisions of Family Practice, "The Divisions", will remain confidential. I will not share or reveal any personal information I learn as a member of this organization.I acknowledge and agree that the information in this Membership Registration form is collected to confirm membership in the Division and may be used for the purposes of communication any information from the Division that is deemed necessary. The information collected will remain the confidential property of the Divisions and will not be shared with any third parties, with the exception of the Doctors or BC/FPSC which may need membership information to assess and allocate the appropriate funding to the Division.*

I Agree

Signature*