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Name (first and last)
Email address
Health professional role
Family physician
Resident physician
Other physician (please specify)
Physician Assistant
Nurse practitioner
Nurse
Pharmacist
Dietitian
Social Worker
Administrator
Researcher
Medical student
Other learner (please specify)
Other (please specify)
Primary care practice Type
Family Health Group (FHG)
Fee for Service (FFS)
Family Health Network (FHN)
Family Health Organization (FHO)
Family Health Team – Family Health Network (FHT – FHN)
Family Health Team – Family Health Organization (FHT – FHO)
Comprehensive Care Model (CCM)
Community Health Centre (CHC)
Rural Northern Physician Group Agreement (RNPGA)
GP Focused Practice
N/A
Other (please specify)
Where do you work?
City/Town/Community
Province/Territory
Country
How did you hear about these modules:
DFCM listserv
OMA newsletter
COVID-19 Community of Practice
Social media
OCFP newsletter
Other (please specify)
Would you like to receive an email when there has been a major update to the content of the module?
Yes
No
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