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Locum Registration

Please submit this registration form for any locum clinician providing care in your office.

This information will be captured in our database, and circulated to program managers and staff so that we are aware of who might be referring to HFHT programs and services.

Name of Person Completing the Form and their Practice

Locum Name

Locum Email

Please indicate the locum's profession

Start Date

End Date (if known)

Number of Days Per Week

Will the locum be providing ongoing practice coverage?

Yes

Unknown

Please list names of all physician members that this locum will provide coverage for.