First Name
Last Nam *
Gender *—Please choose an option—Select GenderMaleFemale
Email Address *
Phone Number *
City of Residence *
State of Residence *
University *
City of University * *
State of University *
Expected Date of Graduation *
Select your field of studySelect Field of StudyPsychiatryDermatologyCardiologyFamily PracticePediatrics
Number of clinical hours needed *
3 max characters.
Clinical Rotation Start Date *
What is the date when you are allowed by your university to begin your clinical rotation?
Rotation PreferenceIn PersonTelehealthHybridNo Preference
Please keep in mind that your university may not allow telehealth and/or hybrid. Be sure to confirm with your school
Are you willing to travel?No< 50 miles< 150 milesMore than 150 miless
Years of preceptor experience required *1 year2 yearsNo Requirement
Some schools require that your preceptor must have a certain amount of professional experience
Additional Comments
Please let us know if you have any additional comments or you'd like to clarify any of your responses
