Inspection Program - Change in Premises IVIT Personnel & Professional Corporations Form

Premises are required to ensure that the College has up-to-date and accurate information about all of the Naturopathic Doctors performing IVIT procedures (compounding for and administering IVIT) within your premises.

Please use this form to inform the College of a change in the designated Registrant (DR), the IVIT Naturopathic Doctors, and their health professional corporations (where applicable) that are associated with the premises.

PREMISES INFORMATION

Clinic Name

Please provide the name of the registered premises.

Street Number and Name

Please provide your street number and street name, or postal box number for your mailing address.

City, Town or Community

Please provide the city, town or community for your mailing address.

Province or Territory

Please select the Province or Territory for your mailing address.

Postal Code

Please provide the postal code for your mailing address.

DESIGNATED REGISTRANT INFORMATION

Please provide the following information about the Designated Registrant currently listed with the College for this premises. This should be completed even if you are now intending to identify a change in the Designated Registrant.

Designated Registrant Name

Please enter the name of the Designated Registrant for this premises.

Designated Registrant Registration Number

Please enter the registration number for the Designated Registrant.

PERSONNEL CHANGE INFORMATION

Personnel to be Updated

Designated Registrant

Health Professional Corporations

Practising Naturopathic Doctors

DECLARATION AND SIGNATURE

Declaration

I hereby declare that, to the best of my knowledge, the information on this form is true and complete. I understand and agree that it is professional misconduct to make a false or misleading statement.

I agree

I do not agree

I voluntarily sign this form and affix my digital signature.

Signature

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

I voluntarily sign this form and affix my digital signature.

COPY OF SUBMISSION

Below is a check box to enable you to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address. 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

Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.