Doctors Leave Form

Doctors Name: *

Inpatients First Date of Leave *

Inpatients Last Day Of Leave *

Inpatients Return Date *

Outpatients First Date of Leave *

Outpatients Last Date of Leave *

Outpatients Return Date *

Will you continue to see inpatients during your leave period? *

YesNo

Are you available for the on-call roster during this time? *

YesNo

What dates are you available for the on-call roster during this time?

Notice of Leave as per by Laws

Annual Leave Form must be completed prior to taking leave. An Accredited Practitioner must notify the Chief Executive Officer of the Hospital in writing, at least four weeks in advance of holidays and advise of coverage arrangements. Doctors are to coordinate their leave with the other doctors from South Coast Private Hospital to ensure there is adequate care for the hospital.

REMINDER: All doctors are to ensure they complete Form AD-66 Doctor to Doctor Transfer of Care 2 business days prior to leave.

Dr Signature *

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Date *