Reappointment Application - Dental

Reappointment Application for Dental Staff (July 1, 2024 to June 30, 2025)

Instructions

Please complete the following reappointment application. Make sure you have proof of membership with the R.C.D.S. to submit with your application as you will be asked to upload.

You will not be able to save this application and return to add your documentation.

I, hereby apply for reappointment to the dental staff of the Sault Area Hopsital,(Required)

(enter your name)

As a member of the:(Required)

Please indicate any CHANGES to the folowing information:

Home Address

Home Phone

Office Address

Office Phone

Mobile Phone

Pager Number

Fax Number

In applying for reappointment I am requesting privileges as approved and attached to my previous application with the following changes (additions or deletions):

Education

In making this application, I provide the following record of my continuing education and contribution to the hospitals' operation:

1. Continuing Dental Education:

a) Post-graduate courses attended (names of courses, locations, dates attended):

b) Degrees, diplomas, etc. attained during the year:

c) Conventions and special meetings attended (location, name of meeting and date):

2. Service to Other Hospitals and Health Organizations During the Past Year:

(Other health Organizations including the O.D.A., District Health Council, local allied health groups, etc.)

Please identify positions held, committee representation and organization:

Professional Conduct

4. Have you been the defendant in any malpractice litigation or any litigation related to the practice of medicine during the past five (5) years in which a finding of negligence was made against you or in which negligence was admitted by you or on your behalf?(Required)

Yes

As the answer is YES to question 4, please provide details related to when, where, the circumstances regarding your involvement, and the disposition of the action.(Required)

Emergency Contact Information

This information is helpful if the hospital needs to contact someone on your behalf:

Name

Surname (last name) Given name(s)

Relationship to Applicant

Phone (daytime)

Phone (other)

Home Address

Street Address Address Line 2 City Province Postal Code

Requirements

Please attach evidence of membership with the R.C.D.S.(Required)

Drop files here or

Max. file size: 100 MB.

Date

Name

First Last

Preferred Email(Required)

A copy of your application will be sent to your preferred email address to verify successful submission.

This field is for validation purposes and should be left unchanged.

Reappointment Application – Dental