* are required fields

First Name*: Last Name*:

Contact E-mail*: Contact Phone*:

License Type*: PA-C MD DO NP Other

If "Other", please specify:

Alternate contact first name:

Alternate contact last name:

Alternate contact email:

Alternate contact phone:

Alternate contact position: Office Manager HR Other

If "Other", please specify:

Preferred method of contact*: E-mail Phone Mail Alternate Contact

Name of Office*:


Street Address*:

Address Line 2:

City*: State*: ZIP*:

Type of Practice*: Family Medicine Pediatrics Internal Medicine (outpatient) Internal Medicine (inpatient) Emergency Medicine OB/GYN General Surgery Orthopedics Psychiatry/Behavioral Medicine Other

If Other, please specify:

Have you ever precepted students before?*       

I am available to take students during the following dates:
Check all that apply and indicate the number of students your practice can accommodate for each rotation.

Rotation Dates*

November 4 2013 - December 6, 2013
December 9, 2013 - January 24, 2014
January 27, 2014 - February 28, 2014
March 3, 2014 - April 4, 2014
April 7, 2014 - May 9, 2014
May 12, 2014 - June 20, 2014
June 23, 2014 - July 25, 2014
July 28, 2014 - August 29, 2014
September 2, 2014 - October 3, 2014
October 6, 2014 - November 7, 2014

How many students are you able to accommodate?*
Please indicate if there are differences between the dates selected.