Adding a Procedure Form

Adding a Procedure Form

The Inspection Program of the College of Naturopaths of Ontario inspects the premises where compounding for and the administration of IVIT are performed. It is necessary for the College to have an up-to-date record of all premises where these services are actively being offered. This requires being informed by the designated Registrant where a premises that only provided one procedure, either only compounding for IVIT or only the administration of IVIT, is now offering both procedures.

The addition of a new procedure at a premises does not require an inspection to be conducted before the new procedure can be performed. The procedure will be included in the inspection of the premises at the next scheduled inspection.

1. IVIT PREMISES INFORMATION

Please provide the following information about the IVIT premises where a new procedure is being added.

Clinic Name*

Number and Street Name*

City*

Province

Ontario

Telephone*

Please select the arrow beside the flag to change it to Canada.

Phone

E-mail address*

2. DESIGNATED REGISTRANT INFORMATION

The designated Registrant is the naturopathic doctor who has been identified as the Registrant who is authorized to deliver and accept information on behalf of the premises. If there is only one naturopathic doctor authorized to perform IVIT procedures in the premises then that Registrant is the designated Registrant. In a premises where more than one naturopathic doctor is authorized to perform IVIT procedures in the premises one of the Registrants must be identified as the designated Registrant.

Last Name of Designated Registrant*

First Name of Designated Registrant*

Registration Number of Designated Registrant*

Email address of Designated Registrant*

Telephone of Designated Registrant*

Please select the arrow beside the flag to change it to Canada.

Phone

3. NEW PROCEDURE BEING ADDED

Please indicate whether the new procedure has already been added to this premises or whether it will be added in the near future.*

Recently added.

To be added in the near future.

Please check the appropriate box to indicate the IVIT procedure that is being added at this premises:*

Administering IVIT

Compounding for IVIT

Date of change*

Please indicate the date that the new procedure began being performed at this premises.

Date to Begin*

Please indicate the date that the new procedure will be performed at this premises.

4. DECLARATION AND SIGNATURE

Please review the following declaration and the signature you are being asked to provide carefully.

Declaration*

The information that I have provided is true and accurate to the best of my abilities. I understand that it may be considered an act of professional misconduct to make a false or misleading statement.

I agree

I do not agree

Signature

By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein was completed by you and is bound directly to you.

I voluntarily sign this form and affix my digital signature.*

5. Submission Copy

Below is a check box to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address for a second time. This will enable the on-line system to send you a copy of the information that you have provided to the College.

Send me a copy of my responses

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