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

Please provide the name of the registered premises.

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

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

Please select the Province or Territory for your mailing address.

Ontario
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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.

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

Please enter the registration number for the Designated Registrant.

PERSONNEL CHANGE INFORMATION

REPLACING THE DESIGNATED REGISTRANT

You have indicated above that you wish to change the person who is the Designated Registrant (DR) for your premises. As you have already provided the name of the current DR, the College will remove that person and replace the DR with the new information you provide below.


Please provide all of the following information even if the new DR is someone who is presently identified as a practising ND at this premises.

Phone
Status of Outgoing Designated Registrant*

Please indicate whether the outgoing Designated Registrant will be continuing to perform IVIT procedures at this premises. If you indicate "yes", they will be removed as Designated Registrant; however, they will be added as a practising ND at this premises.


Please note, you do not have to request this change for the DR in the ND listing on this form.

UPDATING HEALTH PROFESSIONAL CORPORATIONS

This section is used to update the Health Professional Corporations for the NDs who are performing IVIT at this premises. Health Professional Corporations are tied to one or more Naturopathic Doctors and not to specific clinics or premises. The College requires that the information it has about the Health Professional Corporations operating out of a premises be kept up-to-date and accurate.

Health Professional Corporation Changes to be Made*

Please select which of the following you are doing with the listing of Health Professional Corporations operating out of this premises.

Please note that the following information must be provided:

Corporation Name and Corporation registration number.


This information is available from the Colleges Professional Corporations Search feature on the website.

Please note that the following information must be provided:


Corporation Name and Corporation registration number.


This information is available from the Colleges Professional Corporations Search feature on the website.

UPDATING THE LIST OF PRACTISING NATUROPATHIC DOCTORS

This section is used to update the list of Naturopathic Doctors performing IVIT procedures at this premises. To review who is presently listed as NDs performing IVIT procedures at this premises, please search for this premises in the IVIT Premises Search feature on the College's website.

Changes to the ND listing to be made*

Please select on of the following option in terms of the changes you wish to make to the list of NDs practising in this premises.

Please note that the following information must be provided:

Full name (first and last) of the ND, and the ND's registration number.


The list of NDs currently listed as performing IVIT procedures in this premises may be found by reviewing your premises listing on the IVIT Premises Search directory. To find the full name and registration number of an ND you wish to add, please refer to the Naturopath Search feature on the College's website.

Please note that the following information must be provided:


Full name (first and last) of the ND, and the ND's registration number.


The list of NDs currently listed as performing IVIT procedures in this premises may be found by reviewing your premises listing on the IVIT Premises Search directory. To find the full name and registration number of an ND you wish to add, please refer to the Naturopath Search feature on the College's website.

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.

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.


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.

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