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Physician Informational Data Sheet
Camp Name
Dates of Service
1. Physician's Full Name
2a. Work Address
2b. Cell Phone
2c. Email Address
3. Medical Specialty
4. Are you board certified in your specialty?
Yes
No
If No, are you eligible?
Yes
No
5. License Number(s) and State
State
Permanent or Temporary?
Permanent
Temporary
*Please verify that your current state license will not expire while at camp, if so; Please provide a copy of your renewed license as soon as possible.
6. What are your specific responsibilities and duties in regard to the work you perform for the camp?
Yes
No
If yes, please explain
7
Do you plan on performing any surgery on behalf of the camp?
8
Do you plan to administer any anesthesia on behalf of the camp?
9
Have you ever had a malpractice claim or suit filed against you?
10
Have you ever had your license revoked, suspended, restricted or placed on probation?
11 a
The subject of an investigatory or disciplinary proceeding or reprimand?
11 b
Convicted for an act committed in violation of any law or ordinance other than traffic offense?
11 c
Treated for alcoholism or drug addiction?
12
The name of your malpractice insurer (if none, indicate accordingly):
13
Does this Malpractice Policy cover you for your acts at the camp?
This form was completed by:
First Name
Last Name
Title
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