Register As Physician

Thank you for applying to the Manitoba Locum Tenens Program. The first step in the process is to completing the application below. Please allow up to 10 days for your registration to be completed. Once submitted your credentials will be verified and you will be notified of acceptance into the Manitoba Locum Tenens Program Pool of Physicians.

The following documentation will be required prior to acceptance:

• Certification that Locum Physician is fully licensed and registered to practice medicine in the province of Manitoba.
• Proof of membership in good standing with the Canadian Medical Protective Association
• Certified copy of Medical Degree
• Certified copy of LMCC or CCFP
• Certified copy of Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) when required (facility dependent)
• Rural and Northern Locum Physicians will be required to sign an Independent Contractor Medical Services Agreement with the Manitoba Locum Tenens Program outline the Program and Physicians responsibilities.
• Urban Pilot Program Locum Physicians will be required to sign a contract with the Manitoba Locum Tenens Program outlining the Fee-for-service compensation model, 15% overhead hold back and Program and Physician responsibilities.

* = required

Personal Information
* Physician First Name:
* Physician Last Name:
What languages do you speak fluently?	English    French    Other
* Billing Number:
* Desired Locum Type:	Rural / Northern Urban Both
* Desired Schedule Type:	Full Time Partial or Part Time Both
* Desired Workplace Regions:	Interlake Eastern Health Authority   Northern Health   Prairie Mountain Health   Southern Health-Santé Sud   Winnipeg Regional Health Authority   Specific Facility
Contact Information
* Address:
* City:
* Province:	Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
* Postal Code:
* Phone 1:	Alternate Work Phone Fax Number Home Phone Mobile/Cellular Phone Pager Number Work Phone   ext.
Phone 2:	Alternate Work Phone Fax Number Home Phone Mobile/Cellular Phone Pager Number Work Phone   ext.
Phone 3:	Alternate Work Phone Fax Number Home Phone Mobile/Cellular Phone Pager Number Work Phone   ext.
* Email 1:
Email 2:
Medical Services Information
	By clicking on this check box, I am signifying that I maintain a valid license and I am eligible to practice medicine in the province of Manitoba.
Certifications:	PALS     ACLS     ATLS     CMPA     Other
* CPSM#:
CCFP#:
* Medical School:
* MD Year:	January February March April May June July August September October November December 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950
* Specialty:	Allergy & Immunology   Anesthesiologist   Cardiology   Dermatology   Emergency Medicine   Endocrinology   Family Medicine   Gastroenterology   General Surgery   Geriatric Medicine   Gynecology   Hematology   Hospice & Palliative Medicine   Hospitalist   Infectious Diseases   Internal Medicine   Neonatology   Nephrology   Neurology   Neurosurgery   Obstetrics   Oncology   Ophthalmology   Pathology   Pediatrics   Pulmonary Disease   Radiology   Rheumatology   Thoracic Surgery   Other
* Describe Medical Skillset:
What type of EMR have you worked with?	Accuro EMR   ChartStar   Clinisys EMR   InputHealth   LibreMD   Max-Gold9   Profile
Physician Questions
* When you are not working for the MLTP will you maintain a practice elsewhere?	No Yes
* Is this a Full-time or Part-time practice?	Full-Time Part-Time
* Where is the practice located?
* How did you initially find out about the MLTP?	Word of Mouth   Conference   Regional Recruiter   Social Media   Manitobalocum.ca website   Other
* How did you find out about the Urban Locum Pilot Program?	Word of Mouth   Social Media   Website   Doctors Manitoba   Other
* What factors influenced your decision to work within Manitoba?	Family   Location Environment   Change and Variety   Financial reward   Learning opportunities   Other
* What motivated you to register with the MLTP?	Location   Break routine   Gain new perspective   Expand my horizons   Expand CV   Freedom   Flexibility   Network   Share   Contribute   Income   Other
* Are you doing locums as a means to explore full-time practice opportunities?	No Yes
Curriculum Vitae
Upload Curriculum Vitae:	*.pdf, *.doc, *.docx, *.txt, *.rtf @ 1Mb Maximum
Account Information
* User ID:
* Password:
* Confirm Password: