Lawyer

REGISTRATION PAGE

Personal Information
Consent Information Page

Personal Information Page

First Name

Last Name

Phone Number

Office Phone Number

Area of Specialization in law practice

Regulatory Body Registration Number

Mailing Address

Name/Location of Current Practice

For the purpose of registration as a Consult with iConsulMDs, the company requests your response to the following:

1. List all the regulatory bodies with which you are registered.

2. Please also indicate any in which you are not currently in good standing.

Disciplined by a profession regulatory board in Nigeria or elsewhere in the past 5 year ? If yes, state specifically what charges.

Consent Information

Please tick following appropriate statement.

I have been disciplined by a profession regulatory board in Nigeria or elsewhere in the past 5 year. If yes, state specifically what charges.

I have denied provider participation, termination, sanctioned, or penalized by any third-party payor I the past 5 years.

I have been the subject of an allegation, complaint, or investigation by any regulatory board in the past 5 year in Nigeria or elsewhere.

I have been treated for any addictions such as alcohol abuse, drug abuse etc in the past year

I have been affected by a physical or mental condition/illness that may affect my ability to practice my profession.

I have been convicted or charged of an indictable offence under the Nigerian law or under similar legislation outside of Nigeria in the past year.

I have been convicted or charged with an offence under the Drug related offence in Nigeria or under similar laws in any other country in the past year.

This information is being collected under the authority of the individual specific Act for each profession and will be used to determine your eligibility to serve as consultant to iConsuultMDs clien. It is protected by the privacy provisions of the Access to Information and Protection of Privacy Act. I hereby authorize the iConsultMDs to directly contact any professional regulatory body with which the I have been and am currently registered, to obtain information regarding my registration status therein, including the obtaining of letters of good standing.

All information provided is true