Request Form for Seeking Family Physician Representation

INSTRUCTION FOR THE REQUESTER: Alberta’s Family Physician Leadership Secretariat thanks you for your interest in engaging a family physician to be involved in your project. A family physician can provide a unique perspective in health care delivery in Alberta. If you would like to request a family physician to be involved in your work in primary care, policy development, health care system reform, and/or patient care, please complete and submit this form. We ask that you take a moment to read and understand the Guidelines and Process for Seeking Family Physician Representation before you begin. Should you have any questions or issues completing this form, please contact info@engageprimarycare.ca.

Once you have completed the form, an engagement coordinator will review your request and begin the process to find a reasonable candidate that fits with your needs.

Step 1: Organization/Requester

Identify the organization for which you are making this request.

1. Organization: *

1a. Other Organization: *

Requester

2. First Name: *

3. Last Name: *

4. Designation: *

5. Phone #: *

6. Email Address: *