Office of Education Rotation Request

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Office of Education Rotation Request

Office of Education Rotation Request

Use this form to request a rotation at Reliant Medical Group.

Contact the Office of Education

"*" indicates required fields

Name *

First Last

Phone *

Email *

Title: *

Nurse Practitioner

Physician Assistant

Resident MD

Other

If other, please specify

School/Program Associated with *

Department of Rotation *

Start of Rotation *

End of Rotation *

Total numbers of hours needed to complete the rotation:

Total number of days/weeks needed to complete the rotation:

Preferred day(s) of the week:

Anticipated Graduation Date *

Do you have a confirmed preceptor at Reliant *

Yes

If Yes, please provide the name of the preceptor:

Does your program offer a stipend for the preceptor? *

Yes

Unsure

Please provide the Program Coordinator contact information *

First Last

Program Coordinator Email *

Program Coordinator Phone *

Upload your resume/CV *

Accepted file types: pdf, jpg, png, Max. file size: 100 MB.

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