Physician Information Form
Yes   No
Yes   No
* 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.
7. Do you plan on performing any surgery on behalf of the camp?
Yes   No
8. Do you plan to administer any anesthesia on behalf of the camp?
Yes   No
9. Have you ever had a malpractice claim or suit filed against you?
Yes   No
10. Have you ever had your license revoked, suspended, restricted, or placed on probation?
Yes   No
11a. Have you ever been the subject of an investigatory or disciplinary proceeding or reprimand?
Yes   No
11b. Have you ever been convicted for an act committed in violation of any law or ordinance other than traffic offense?
Yes   No
11c. Have you ever been treated for alcoholism or drug addiction?
Yes   No
12. The name of your malpractice insurer (if none, indicate accordingly):
 
13. Does this Malpractice Policy cover you for your acts at the camp?
Yes   No
  To the best of my knowledge, all of the information I have provided is accurate.
This form was completed by: