Physician Questionnaire - cpso.on.ca

Physician Questionnaire The purpose of this Questionnaire is to provide the methadone Committee with the most current information about you and your practice. The information enclosed will be reviewed by the Committee and individuals appointed, to discuss and/or review your practice, and by staff who support the Committee. NAME:: CPSO#: DATE OF BIRTH: SEX: MEDICAL SCHOOL: YEAR OBTAINED: SPECIALTY: YEAR OBTAINED: ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------- PLEASE PRINT LEGIBLY USING BLACK INK ONLY I. What is your practice status? What type of methadone exemption have you received from Health Canada? General Exemption for MMT for Opioid Dependence 1 year General Exemption for MMT for Opioid Dependence 3 year General Exemption for MMT for Opioid Dependence with the added delegation privilege Mailing Address Phone 1: Phone 2: Fax Number: Email Address: Primary Practice Address (location in which you see the majority of your methadone patients) Phone 1: Phone 2: Fax Number: Email Address: Secondary Practice Address Phone 1: Phone 2: Fax Number: Email Address: Updated.

Physician Questionnaire The purpose of this questionnaire is to provide the Methadone Committee with the most current information about you and your practice.

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