Skip to content
HELP Volunteer Physician - Intake Form
Thank you for expressing an interest in volunteering.
Any information you provide in this survey will remain private and confidential. None of your information will be shared without your express consent.
OK
*
1.
Full Name:
(Required.)
*
2.
Email address:
(Required.)
*
3.
Phone number:
(Required.)
*
4.
Are you currently residing in Canada?
(Required.)
Yes
No
*
5.
City/Town:
(Required.)
6.
Province/Territory
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
*
7.
Medical area(s) for which you prefer to help with medical English [select all that apply]:
(Required.)
Anesthesiology
Emergency Medicine
Family Medicine
Hematology
Internal Medicine
Obstetrics and Gynecology
Oncology
Pathology
Pediatrics
Psychiatry
Public Health and Preventive Medicine
Radiology
Surgery
No Preference
Other (please specify)
*
8.
What year did you graduate from medical school?
(Required.)
*
9.
Are you currently
(Required.)
Working full time
Partially retired
Retired
Other (please describe)
*
10.
Which meeting format do you prefer?
(Required.)
In-person sessions
Virtual sessions
Either in-person or virtual sessions are okay
*
11.
Can you make a commitment to meet with a Newcomer Physician for 12 one-hour sessions, meeting approximately once per week?
(Required.)
Yes
No
Current Progress,
0 of 13 answered
