TEMPLATE - Info Sheet - VC

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Interprofessional Core Curriculum an interprofessional workshop Fatigue, Ascites and Hypercalcemia Learn about the management of symptoms and metabolic imbalances by attending: Management of Symptoms and Metabolic Imbalances An interactive and interprofessional education workshop designed to improve collaboration and communication among healthcare professionals who care for patients living with cancer. Thursday, May 14, 2009, 4:00 – 7:30 PM Capital Health – QEII – VG Site, Bethune Building, Room 544 Please arrive 15 minutes prior to the start time of the workshop. Session will be available via videoconference in Bridgewater (South Shore Regional Hospital, Lecture Room 2 and 3). Facilitators: Bruce Colwell, Medical Oncologist, CDHA Leslie McLean, RN, MN, Project Manager, Oncology Services, CDHA This program has been accredited by Dalhousie University Continuing Medical Education and the Division of Continuing Pharmacy Education. For credentialing details, please see the registration form. There is no charge for registration. Space is limited - please register early. To register: Please fax the registration form on the back of this page to Cancer Care Nova Scotia at 902-473-6412, Attention: Allison MacDonald. Registration form is also available at: www.cancercare.ns.ca Management of Symptoms and Metabolic Imbalances Capital District Health - QEII – VG Site Bethune Building, Room 544 Thursday, May 14, 2009 4:00 – 7:30 PM REGISTRATION FORM PLEASE PRINT CLEARLY (Note: We are unable to process illegible or incomplete forms) Name __________________________________________ Email _____________________________ Work Address: Hospital/Facility Name ________________________________________________ Department___________________ Unit __________ Floor _____ Street Number ______________ Street Name ________________________City ___________________ Postal Code ____________ Phone: (W) (____) _______________ (H) (_____) _____________ Fax: (____) _______________ Please check one: Family Physician Physician Specialist – please specify ____________________________________________ Nurse – please specify _______________________________________________________ LPN – please specify ________________________________________________________ Social Worker Spiritual Care/Chaplain Pharmacist Dietitian Other – please specify _______________________________________________________ I work in a: Community setting Hospital setting Long-Term care setting I intend to take part via videoconference in Bridgewater. As an accredited provider, Dalhousie University, CME designates this continuing medical education activity for 3.5 credit hours for MAINPRO M-1 of the College of Family Physicians of Canada and reciprocally for the American Academy of Family Physicians. This event is an accredited group learning Section 1 activity as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada and reciprocally for AMA Category 1 of the Physician’s Recognition Award. This program is accredited for 3.5 CEU’s by the Division of Continuing Pharmacy Education, College of Pharmacy, file number CED-2009-005. The College of Registered Nurses of Nova Scotia has adopted a continuing competence program, “Building Your Profile,” to assist registered nurses with a mechanism to maintain their ongoing competence. Registered nurses, in identifying their learning needs around the care of oncology patients and their families, will benefit from this educational program that engages them in reflective practice and the integration of learning into their practice. CCNS collects and uses your above information for administrative purposes related to this session. For physicians only: this information is also provided to Dalhousie CME for CME credit. CCNS retains this information for follow-up with participants (this may include contacting you for research and evaluation purposes) and to keep a history of an individual’s participation in CCNS educational programs. CCNS does not use or share any individual’s information for other purposes without obtaining the individual’s consent. CCNS Privacy Statement is available on our website. Space is limited – please register early. To register: Please fax this form to 902-473-6412, Attention: Allison MacDonald.

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