Health Professional Award Form

    Candidate Name *

    First Name

    Last Name

    Candidate Phone Number *

    Candidate Email *

    Nominators Name *

    First Name

    Last Name

    Nominators Phone Number *

    Nominators Email *

    Nominator Address

    Street Address

    City

    State / Province / Region

    Postal / Zip Code

    Country

    1) Describe how this health professional demonstrated outstanding patient care on an on-going basis *

    2) Describe how this health professional demonstrates ongoing commitment to better health outcomes for patients. *

    3) Describe any evidence of consumer participation *

    4) Describe how this health professional regularly provides an environment for patients that consistently meets their needs. Does the health professional demonstrate effective communication skills? *

    5) Attach any letters of support from consumers that show evidence that the health professional provides excellent service to patients

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