Thank you for your interest in the Locum Matching Program. Please complete this form in full so that we can create a listing for you and see if we can find a match with our growing list of interested locums. Once completed, email mmclean@divisionsbc.ca to advise your posting is pending.

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* 1. Clinic Name

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* 2. Name of Physician looking for coverage

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* 3. Contact number for Physician looking for coverage (this will be kept confidential)

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* 4. Clinic Contact number (will be part of listing)

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* 5. Clinic website

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* 6. Clinic Address

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* 7. Duration of Locum coverage

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* 8. Estimated Start Date

Date

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* 9. Estimated End Date

Date

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* 10. Could this opportunity begin earlier or end later. Please provide optional start/end dates

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* 11. Proposed Hours

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* 12. Are there specific days or times Locums would be expected work? Please explain. 

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* 13. Obstetrics:

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* 14. Privileges 

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* 15. Residential Care 

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* 16. Palliative Care

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* 17. On Call

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* 18. If being "on-call" is required, please explain in detail how you expect this to be handled/distributed)

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* 19. Solo Practice

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* 20. Do you have any other opportunities at your clinic, in addition to locum opportunities?

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* 21. What is the average number of Patients Per Day

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* 22. EMR used

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* 23. Overhead Split

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* 24. Daily Minimum Wage

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* 25. Travel Expenses reimbursed?

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* 26. Be willing to provide housing arrangement or accommodations?

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* 27. Locum payment based on

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* 28. Please provide additional information about your clinic needs and opportunities for Locums  (this is your opportunity to promote your clinic!)

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