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Request for approval to perform Surgical Privileges

For Consultant Surgeons



Date : ____________
Name : __________________________ License No.: _________________
Professional Title:______________________

Required Documents:
1-A list oI type and number oI procedures perIormed by the Surgeon within the last three
years ( log book) Signed and Stamped by chairperson oI the Dept and Medical Director
oI the Hospital (s) were the Log Book has been issued attested Irom Embassy oI country oI
origin Qatari Ministry oI Foreign aIIaires .
2- Full Address oI the Hospital (s) were the Log Book has been issued ( including the name oI
the hospital , Fax No , Tel No. , P.O.Box , E.mail , Web Site ) Ior VeriIication purpose .

kindly note that you must submit all the required documents other wise your request will be
neglected .

Undertaking:

I. The Consultant :
I hereby declare that all inIormation provided in this request and attached documents are
accurate to the best oI my knowledge.
I hereby undertake not to perIorm any procedure(s) not approved by the Department oI
Medical Licensing; and that I shall bare all legal and disciplinary responsibilities in case
oI violation oI this clause. Further, I declare that perIorming the approved procedures /
treatments will be at my sole responsibility.

Signature: Stamp:

II. The Facility: this medical institution undertakes to provide all requirements that are
legally and/or proIessionally deemed necessary Ior providing quality and saIe care Ior
patients beIore, during and aIter approved surgical intervention (s) are perIormed by this
licensed and privileged Surgeon in this Iacility. The institution also acknowledges to take
Iull responsibility and Iinancial liability in case oI negligence and/or malpractice that
have been proven beyond doubt which have directly or indirectly caused harm and/or
complication(s) to the patient.
Institution: Stamp:

Director : Signature: Stamp:






Request for approval to perform Surgical Privileges
For Specialist Surgeons

Date : ____________
Name : __________________________ License No.: _________________
Professional Title:______________________

Required Documents:
1-A list oI type and number oI procedures perIormed by the Surgeon within the last three
years ( log book) Signed and Stamped by chairperson oI the Dept and Medical Director
oI the Hospital (s) were the Log Book has been issued attested Irom Embassy oI country oI
origin Qatari Ministry oI Foreign aIIaires .
2- Full Address oI the Hospital (s) were the Log Book has been issued ( including the name oI
the hospital , Fax No , Tel No. , P.O.Box , E.mail , Web Site ) Ior VeriIication purpose .

Undertaking:
I. The Specialist :
I hereby declare that all inIormation provided in this application and attached documents
are accurate to the best oI my knowledge.
I hereby undertake not to perIorm any procedure(s) not approved by the Department oI
Medical Licensing; and that I shall bare all legal and disciplinary responsibilities in case
oI violation oI this clause. Further, I declare that perIorming the approved
procedures/treatments will be at my sole responsibility.
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Signature: Stamp:

II. The Consultant : I hereby undertake not to perIorm any procedure(s) not approved
by the Department oI Medical Licensing; and that I shall bare all legal and disciplinary
responsibilities in case oI violation oI this clause. Further, I declare that perIorming the
approved procedures/treatments will be at my sole responsibility.
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,',--' .-=-, ' -=-- -' ',--` -- ,-= '-='-- ,-= '= '-' .
Name : Signature: Stamp:

III. The Facility: this medical institution undertakes to provide all requirements that are
legally and/or proIessionally deemed necessary Ior providing quality and saIe care Ior
patients beIore, during and aIter approved surgical intervention (s) are perIormed by this
licensed and privileged Surgeon in this Iacility. The institution also acknowledges to take
Iull responsibility and Iinancial liability in case oI negligence and/or malpractice that
have been proven beyond doubt which have directly or indirectly caused harm and/or
complication(s) to the patient.

Institution: Stamp:

Director : Signature: Stamp: