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How to get medical documents f... Hamad Medical Corporation Department of Medical Education - GME Office Photo RESIDENCY Programs Selection APPLICATION FORM - 2015 Intake Please read FAQs before completing the Application Form Type or Print in CAPITAL LETTERS. 1. Candidate Name as printed in passport First Middle Family Date of Birth // Place of Birth Nationality dd mm yyyy First Language/s English Arabic Spoken Written Gender Fluent Average Below Average Male Female Other Languages Civil Status Single Married 2. Passport Information Passport No Expiry Date // Resident in Qatar No Yes If Yes then provide QID/RP Expiry Date // 3. Contacts Details Contact Nos. in Qatar Home Mobile Fax Address in Qatar If resident in Qatar Street Name Country P. O. Box Address in Home Country E-mail Address In Case of Emergency person to contact next of kin Name Mailing Address Tel* No* Home Mobile E-mail Attachments Passport copy Qatar ID/Residency Permit 8 photos 1 of 5 4. Education and Qualifications Name of Medical College Country Name of academic degree awarded Date of Graduation // Language used in Medical College English Others 5. Internship/House Officer Appointment First year post graduate training Rotating Internship HMC Other Institution Straight Internship 1st year post graduate training Institution name Country Dates From // To // Medical license no Type Country Validity// 6. Post Graduate Training Country Describe clinical training/work Other academic qualifications i*e* Masters PhD Others Certificates Fellowship or Board Certifications Attachments Copy of medical degree certificate copy of internship certificate copy of medical license copy of clinical experience certificate or research copy of other academic qualification certificates 2 of 5 7. Current Clinical Post Position Title Institution/Hospital name 8. Matching choices Anesthesia Cardio Thoracic Surgery Family Medicine General Surgery Ob-Gyn Internal Medicine Otolaryngology Pediatrics Plastic Surgery Radiology Community Medicine Ophthalmology PM R Emergency Medicine Neurosurgery Orthopedic Surgery Psychiatry Urology Program Choices First Second ACGME-I Accredited Programs 9. Mandatory Enrollment Exams to HMC Residency Programs Exams 3-Digit Score Date No* of Attempts USMLE Step 1 USMLE Step 2 CK Clinical Knowledge IFOM - CSE a* Have you applied for the matching of HMC residency program before If Yes Date/s Program/s b. How did you learn about the Residency Program at HMC Internet/Social Media Newspaper Advertisement Friend Staff at HMC c* Did you apply for the Residency Program from outside Qatar If Yes pls. specify the country 3 of 5 d. Is your spouse working at HMC Yes f* Are you applying under the Sponsorship Program Yes 10. English Language Required Competency Exams Score IELTS TOEFL IBT / CBT / PBT If not available yet attached registration copy 11. Please indicate if you have done any the following a* Have you previously had a Clinical Attachment at HMC Yes b. Have you had any publications published or taken part in any scholarly activities previously If Yes please list the recent c* Have you attended any courses/workshops previously Yes 12.

Medical documentation form CIVILIAN MEDICAL DOCUMENTATION FORM DATE: Name Last First Bureau Title Absent From AM PM Date: Shield (if applicable) AM PM Absent From SSN Total Days /Hours Date: I was unfit for duty on account

Nevada wic medical documentati... NEVADA WIC MEDICAL DOCUMENTATION FORM Participants Name Date of Birth Parent/Caregiver First & Last Name Standard Formulas Nevada WIC provides the following standard formula: Similar Advance and

Florida department of health w... Enfamil Infant milk-based formula 60 40 whey-to-casein ratio 400 IU vitamin D in 34 oz Enfamil Gentlease partially hydrolyzed milk-based formula 60 40 whey-to-casein ratio 20 lactose Enfamil Reguline partially hydrolyzed milk-based formula 60 40 whey-to-casein ratio 50 lactose and a blend of two prebiotics--galacto-oligosaccharide GOS and polydextrose PDX Enfamil A. Enfamil milk-based formulas and Gerber soy-based formulas are the WIC contract formulas. See the back of this form for more information about the WIC contract formulas. If you have a question about a specific formula please contact your local WIC office or the Florida WIC Program at 1-800-342-3556. Florida Department of Health WIC Program Medical Documentation for Formula and Food The Florida WIC Program supports the American Academy of Pediatrics Statement on Breastfeeding and the Use of Human Milk. Enfamil Newborn milk-based formula 80 20 whey-to-casein ratio To be discontinued by manufacturer in May 2017. Local WIC agency staff can assist WIC mothers with breastfeeding or make appropriate referrals. breastfeeding. An extensively hydrolyzed formula or amino acid based formula can be provided for a diagnosed formula intolerance or food allergy to lactose sucrose milk protein or soy protein. Formula or WIC-Eligible Nutritionals will be considered for a diagnosis of following at or below 5th percentile weight-for-length on WHO growth charts for ages under 24 months OR at or below 5th percentile BMI-for-age on CDC Growth Charts for ages 24 months and older OR both the length/height for age and weight for age are at or below the 5th percentile OR has dropped one growth channel in a 6-month time period which results in the child being below the 25th percentile weight-for-length or BMI-for-age. Use of the WIC contract formulas provides additional funds for the Florida WIC Program to serve more pregnant breastfeeding and postpartum women infants and children. Completion of this form is not needed for infants under 12 months of age to receive a WIC contract formula. WIC contract standard infant formulas are the following formulas Note All contract formulas have DHA and ARA. Failure to Thrive must be accompanied by current height or length and weight. MILK SUBSTITUTES and OPTIONS - Only complete this section when applicable. Requests are limited to 6 months. It is our policy to re-evaluate the client s continued need for the formula s on a periodic basis during the requested time period. Feeding difficulty without giving medical diagnosis. Medically necessary without giving medical diagnosis. Poor weight gain without giving medical diagnosis. Enhancing nutrient intake or managing body weight. Feeding difficulty without giving medical diagnosis. Medically necessary without giving medical diagnosis. Poor weight gain without giving medical diagnosis. Enhancing nutrient intake or managing body weight.

Georgia medical documentation... 1 Georgia WIC Program Medical Documentation Form for WIC Special Formulas and WIC Foods Patient s First & Last Name: Date of Birth (MM/DD/BY): Parent/Caregiver s First & Last Name: 1. Qualifying Medical

Va0857e request for medical do... REQUEST FOR MEDICAL DOCUMENTATION 1. DATE2. Dear Health Care Provider: Your patient has requested an accommodation (describe the requested accommodation here)because of functional limitations caused

Www doh wa govportals1washingt... WIC Fax: Date Form Expires: Medical Documentation Form: Sections 14 MUST be completed. Infants not exclusively breastfed are provided Similar Advance, Similar Sensitive, Similar Total Comfort or Similar

Medical documentation form 614... Florida WIC ProgramMedical Documentation for Formula and Footplate have the client/caregiver return this completed form to the WIC office or Fax it to the WIC office. The Florida WIC Program supports

New patient packet female paci... Patient Name: Date of Birth: Todays Date: FirstMiddle InitialLastPACIFIC UROLOGY 100 N. WIGET LANE, SUITE 290, WALNUT CREEK, CA 94598 (925) 9377740, FAX (925) 9339868 2222 EAST STREET, SUITE 250,

New patient packet allergy and... Allergy, Asthma, and Immunology Childrens Hospital of The Kings DaughtersPharmacy & location: Allergy/Asthma Questionnaire Please take a few moments to tell us about your childs medical history

New patient packet ubmd orthop... DOCUMENT NO: FRM003.02AK REVISED 11.30.2018NEW YORK MOTOR VEHICLE NOFAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02) Claim Number:I,, ( "Assignor

New patient packet fillable an... HEAD & NECK ASSOCIATES OF ORANGE COUNTY, INC. Bredenkamp CHO Crockett Jacobsen Lulu Funds Space Thompson Wells Wohlgemuth PATIENTINFORMATION NAME: BIRTH SEX:MF LastFirstMI Nickname ADDRESS:

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