Core Rotation Preceptor Form

Clinical Rotations

Emergency Medicine, General Surgery, Internal Medicine, Orthopedics, Pediatrics, Prenatal Care/Gynecology, Psychiatry, Family Medicine I, Family Medicine II, Elective I and Elective II

Are you interested in being a clinical preceptor?*

Yes

How many students could you precept during the clinical year?

Your Title

First Name

Middle Name

Last Name

Suffix

Degree

Speciality

Practice Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Practice Manager or Contact Name

Phone Number

Fax

Hospital/Surgical Center Affiliation(s)

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