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.

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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