Noorda-COM Preceptor Credentialing Form

Thank you for your interest in becoming a partner with Noorda-COM.

We look forward to working with you.

Date*

Physician Contact Information

First Name*

Last Name*

EmailAddress*

The email you list is the email you will use to access Noorda resources.

Cell Phone*

Phone

Opt-in to receive SMS messages*

Select or enter value

Birth Date*

Physician Education/Certification Information

Medical School graduated from*

Degree / Title*

Certifying Board*

Example: American Board of Family Medicine

Specialty*

License Number*

AOA or AMA ID for CME

Clinical Faculty Interest*

Please select all that apply

Select

Site Information

Primary Practice Location Name*

Primary Practice Address*

Primary Practice Address Line 2

Primary Practice City*

Primary Practice State*

Select

Primary Practice Zip*

Primary Practice Phone Number*

Phone

Primary Practice Setting (Multi Select)*

Select

Primary Practice EMR*

Do you have additional practice locations?*

Select

Secondary Practice Location Name

Secondary Practice Address

Secondary Practice Phone Number

Secondary Practice Setting (Multi Select)

Select

Secondary Practice EMR

Affiliated Hospital(s)*

Please select the facilities that you interact with the most and would like our students to be credentialed with.

Select or enter value

Do you have any additional hospital affiliations not listed above?

Select

Additional Hospital Name

Additional Hospital Address

Please include city, state and zip

Office Contact Person

Name*

Designation/Assistant Type*

Please choose all that apply. If not listed, please add designation type

Select or enter value

Email*

Phone Number*

Please describe the type of rotation students will have with you (any extra description is appreciated).

Examples:

This would be a great 2 week elective.
Students will work at multiple location sites.
4-week rotation, heavy neuro autonomy needed, will see a lot of procedures.

Questions or Comments

Documents

Please upload the documents listed below (Images are acceptable)

CV
Any other documentation you wish to include (Head Shot Photo, Medical Malpractice Insurance, Medical School Diploma, Residency Certificate, etc.)

*If you are unable to upload documents at this time, we will reach out to your office contact to request this information on your behalf.

Drag and drop files here or

Send me a copy of my responses

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