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Southern Medical Program - Standardized Patient Application

Please note applicants must be based in the Okanagan to participate in the Standardized Patient Program with the Southern Medical Program.

First Name:

Last Name:

Gender:

Date of Birth (Day/Month/Year):

Email Address:

Phone Number:

Address (Street, City, Province, Postal Code):

Why are you interested in becoming a standardized patient?

How did you hear about the standardized patient program?

This is a confidential survey which will collect personal information such as your name, contact information, and information about your health history. UBC is collecting this information under the authority of section 26(c) of the British Columbia Freedom of Information and Protection of Privacy Act (FIPPA). This information will be used to assess your suitability for participation as a volunteer.
If you have any questions or concerns about the collection or use of this information, please contact:
SMP Patient Programs
smp.patient@ubc.ca
(250) 980-1329