Outstanding Family Physician 2018 - Nomination Form
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Department of Family Medicine – Calgary Zone, Alberta Health Services
What is your full name? (First & Last)
What is the best phone number to reach you on in case we have any clarifying questions?
What is your primary e-mail address?
This will be our main way of contacting you to follow up on the nomination process.
What is the full name of the family physician that you would like to nominate?
Where does this family physician work?
How long has this Family Physician been your doctor?
They aren't my Family Doctor ... yet!
Less than 1 year
16+ years or more
Overall, how satisfied are you with your Family Physicians qualities and traits?
1 -unsatisfied 5- very satisfied or NA =Not Applicable
Assessment of Condition & Ordering Appropriate Tests
Timely Referrals & Follow Up
Respects Personal Values of Patients
What makes you feel that your Family Physician is the best in Calgary?
How did you hear about the Outstanding Family Physician Award?