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Name (First, Last)
Area of Practice
Family Medicine
Women's Health
Pediatrics
Surgery
Internal Medicine
Behavioral Medicine
Emergency Medicine
Other
Title
Physician Assistant (PA-C)
Physician (MD, DO)
Other (please list below)
Hospital Affiliation/Practice Name (Department)
Practice address
Email
Phone number
Student rotations will last for 4 weeks. Which month(s) in 2027 are you available to precept during the clinical year?
January
February
March
April
May
June
July
August
September
October
November
December
Do you have capacity to precept more than one learner at a time? If so, how many?
Are there other providers within your practice that may also have a desire to precept?
No
Maybe
Yes (add contact info below)
Practice Administrator or Manager (name)
Practice Administrator or Manager contact info (email/phone)
Please upload a current copy of your CV. CVs are stored for ARC-PA compliance and will not be shared with students, or anyone outside of the Physician Assistant Studies Department.
Drop files or click here to upload
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