Preceptor Information Form

Your Name(Required)

First Last

Name on licensure/alternative names

First Last

Credentials(Required)

Practice Type(Required)

What states are you licensed in?(Required)

National Certifications(Required)

Work Phone(Required)

Work email or email you check regularly(Required)

Personal phone

Personal Email

What is your usual schedule at your place of employment?(Required)

What is your average daily patient volume(Required)

What is the average age range of your patients?(Required)

What is your average patient acuity(Required)

Placement decisions may be influenced by the acuity of patients

What is your experience as an advanced provider (MD, DO, NP, etc) in years?(Required)

Prescription Authority(Required)

Yes

Precepting Experience (years)(Required)

This upload will only accept “.doc” and “.pdf” file extensions. If you have your social security number on any of these documents, please redact it before uploading. As part of credentialing, we require a copy of your CV/Resume, license, and certification documents. The documents will be held securely in our system. * Required

Document Upload

Upload CV, License, and Certification Documents(Required)

Word documents and PDF can be uploaded. Please include all three pieces of documentation.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

Clinical Site

Please let us know about the location where you will be hosting students and where you are employed.

Name of Clinical Site(Required)

Clinical site's physical address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Average daily patient interactions(Required)

Contact Person

Information on contact person for clinical site.

Do you have an administrative assistant or someone at the site who coordinates providers?

Yes

Name

First Last

Phone

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Preceptor Information Form