DECLARATION OF CLINICAL COMPETENCE

CONSULTANT ORTHOPEDIC SURGEON

Full Name: _____________________________________________________________________________________

Position Applied For: ________________________________________________________________________
Professional Qualifications: ________________________________________________________________

Dear Doctor,
It is important that you complete this Declaration of Clinical Competence as specified below in order to offer you the Initial Clinical
Privileges to start patient care practice in Dr. Sulaiman Al Habib Medical Group in the event you are selected for employment. You may
consider your past experience and existing clinical privilege in the declaration. You may further add remarks in the column provided or
include additional competence, if necessary.

No of Procedures Self Rating Remarks

Clinical Activity/Procedure Performed Fully Competent Needs Supervision
General Activities
Consultation & management of clinic patients
Not Applicable
Admission of patients for management
Refer patients to other consultants for opinion
Offer advice, opinion & treatment to referred
patients
Arthroscopy
Ankle
Elbow
Not Applicable
Hip
Knee
Shoulder
Wrist
Cervical Spine
Closed or open reduction
Discectomy and fusion
Fusion for instability
Internal fixation
Posterior or Decompression & fixation
Disc Replacement
C2 Fractures
Percutaneous Discectomy
Pediatric Procedures
Congenital Anomalies
Congenital Deformities
Congenital Dislocations
Hand
Closed or open reduction
Internal or external fixation
Amputation
Arterial Repair
Arthrodesis
Extensor Tendon repair
Flexor tendon repair, graft
Nerve repair, primary / secondary
Reconstructive surgery
Hip
Closed or open reduction
Internal or external fixation
Arthrodesis
Hip disarticulation
Prosthetic replacement
Reconstructive surgery
Total hip replacement
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 Lower Extremity
Closed or open reduction
Internal or external fixation
Amputation
Arterial repair
Arthrodesis
Nerve repair
Reconstructive surgery
Tendon repair/transfer
Total Knee replacement
Pelvis
Closed or open reduction
Internal or external fixation
Thorasic & Lumbar Spine
Closed or open reduction
Internal fixation
Discectomy
Fusion
Scoliosis correction
Upper Extremity
Closed or open reduction
Internal or external fixation
Amputation
Arthrodesis
Reconstructive surgery
Other Procedures
Amputation
Acromioplasty – hip surgery
Aspiration of joints
EUA
Exc. Biopsy, bone
Exc. Biopsy,soft tissue
Excisional biopsy
Exostosectomy
Manipulation with x-ray (M)
Neuroma, excision, release
Removal of foreign body
Synovectomy
Tenosynovectomy
Pain management injection
Lumbar Disc replacement
Endoscopic & minimally invasive spine
Other diagnostic procedures
Discography
Myelography
Arthrography
Fluoroscopy
Other therapeutic procedures
Chemo-nucleolysis
Other competence, if any, please include below

Declaration
I certify that the competence declared above are true and accurate to the best of my knowledge; any misrepresentations will disqualify my
application from initial clinical privileges and void my employment process/status at Habib Medical Group.

Signature: _______________________________ Date: ___________________________

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