clinical case study cover sheet - Faculty of pain medicine

CLINCAL CASE STUDY COVER SHEETThis completed Cover Sheet is to be returned to the Faculty of Pain Medicine with theClinical Case Study.Trainee: _______________________________________________________________Supervisor of Training: _________________________________________________Title of Case Report: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________Name of Supervisor of Training_____________________________Pain Management Centre____________________________________Signed by Supervisor of Training_______________________________Signed by TraineePlease ensure that all instructions as outlined in the document ‘Clinical Case StudySubmission’ have been complied with prior to the submission of the Clinical Case Study.Page 1 of 2

CLINCAL CASE STUDY COVER SHEETThis completed Cover Sheet is to be returned to the Faculty of Pain Medicine with theClinical Case Study.Title of Clinical Case Study: _________________________________________________________________________________________________________________________Word Count: __________________________________________________________Supervisor of Training to indicate the methodology used by the trainee for sourcingreferences:(please do not the mention the name of the Supervisor of Training, Trainee or Pain ManagementCentre on this page)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please ensure that all instructions have been complied with prior to the submissionof the Clinical Case Study. Page 2 of 2