Preceptor Contact Form

Preceptor Contact Form

Preceptors are an integral part of Rocky Vista University as they give our students hands-on training in the real world with real patients.

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First Name

Last Name

Title:

Gender

Male
Female

Date of Birth

Race/Ethnicity

Cell Phone

Office Phone

Email Address

Fax Number

Practice Name

If other, please explain:

Practice Address

Does this practice offer TeleMedicine?

Practice City

Practice State

Practice Zip Code

Professional School

Grad Year

Degree Earned (i.e. - DO, MD, PA, ANP, etc.)

Are you certified?

Board Certified
Board Eligible
Not Certified

License Number

State

Licensure Type (e.g. Medical)

Licensure Expiration Date

List the hospital(s) used in your clinical practice (to ensure we have appropriate Affiliation Agreements):

Have you had any prior experience precepting/teaching medical students, residents, fellows, nurses, nurse practioners, physician assistants, or EMTs?

Students Accepted for Rotation (REQUIRED):

Third-year medical students
Fourth-year medical students
Physician Assistant students

Would you like an Adjunct Clinical Faculty Appointment from Rocky Vista University?

Please attach your CV below (.docx, .pdf):

If you have issues submitting the form, please remove any commas, spaces, or other special characters from the file, re-upload, and contact us if you are still experiencing problems.

Choose a file

Please attach your Certificate of Insurance (COI) below (.docx, .pdf):

If you have issues submitting the form, please remove any commas, spaces, or other special characters from the file, re-upload, and contact us if you are still experiencing problems.

Choose a file

COI Expiration Date:

Jenzabar University

Clinical Education