Providing Practitioner Initial Date Independent Confirmation Occurred Independent medical opinion provided by: Last Name First Name Mailing Address City/Town Province Postal Code Telephone Number Registration # AB If yes, indicate what type of professional you consulted (select all Did you consult with health care that apply): professionals, such as a psychiatrist or the Nurse patient’s primary care provider, or social Oncologist workers to inform your assessment (do not Palliative care specialist include the mandatory written second Primary care provider assessment required by the Criminal Code): Psychiatrist Yes Psychologist No Social worker Speech pathologist Other health care professional. Specify Section 6: Approval Status
Date Independent Confirmation Occurred Providing Practitioner Initial Independent medical opinion provided by: Last Name First Name Mailing Address City/Town Province AB Postal Code Telephone Number Registration # Did you consult with health care professionals, such as a psychiatrist or the patient’s primary care provider, or social workers to inform your assessment (do not include the mandatory written second assessment required by the Criminal Code): Yes No If yes, indicate what type of professional you consulted (select all that apply): Nurse Oncologist Palliative care specialist Primary care provider Psychiatrist Psychologist Social worker Speech pathologist Other health care professional. Specify Section 6: Approval Status
if-hp-maid-providing-practitioner-record.docx