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Email Address *

First Name

Last Name

CPSO#

Primary Practice Address

Address Line 2

City

State/Province/Region

Postal / Zip Code

Country

Primary Practice Postal Code *

Practice Phone Number

() -(###) ###-####

What type of practice model do you work in? *

Family Health Group (FHG)
Family Health Organization (FHO)/Family Health Network (FHN)/Family Health Team (FHT)
Community Health Centre (CHC)
Independent Practice
Other

Do you serve an underserved FSA? (L5A,B,M,N) *

Would you like to be registered for SCOPE? *

Yes, I agree to be enrolled in SCOPE and consent to my answers to be used for quality improvement purposes.
No, I prefer not to be enrolled in SCOPE.

Are you accepting new patients? *

If yes, how many patients are you accepting? *

Select your desired engagement level(s)

Level 4: Leading (Providing leadership on specific initiatives)
Level 3: Advising (Member of advisory committee(s) as needed)
Level 2: Engaged (Attending engagement events; Providing feedback e.g. completing surveys)
Level 1: Informed (On distribution list to receive regular news and updates)