eDOCSNL Expression of Interest Form

Purpose: This document identifies interest in the program and collects necessary contact information.

Privacy Disclaimer: Personal information collected on this form is collected under the Newfoundland and Labrador Access to Information and Protection of Privacy Act and will only be used for the administration of eDOCSNL. Inquiries about the use and protection of this personal information should be directed to the ATIPPA Coordinator at NLHS.

Clinic Legal Name
Corporation Number
Street Address
Main Phone
Fax Number
Clinic Email (if applicable)
Clinic Website (if applicable)
Primary Contact Name
Primary Contact Phone
Primary Contact Email
List Clinicians in the Clinic
Additional Information (if applicable)
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