Family Medicine Preceptor Form

Are you interested in being a clinical preceptor?

Yes

Students will spend 10 weeks in Family Medicine; 5 weeks at the beginning of the year and 5 weeks at the end of the year returning to the previous Family Medicine preceptor. This structure allows both the student and preceptor to see improvements and progress in the student’s performance over the year.

2020-2021 rotation dates:

JULY 13, 2020 –AUGUST 12, 2020 (Part I)
AND
MAY 10, 2021 – JUNE 8, 2021 (Part II)

Preceptor Availability

I am available for both Part I and II of family medicine

I am available for Part I only. Please contact me for additional date options for Part II

I am available for Part II only. Please contact me for additional date options for Part I

I am interested, but unfortunately I am unavailable during this clinical year

Please keep me on your preceptor list

Title

First

Middle

Last

Suffix

Degree

Practice Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Fax

Practice Manager and/or Contact Person

Hospital/Surgical Center Affiliation(s) (list only if student will accompany you)

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