GUTHRIE: VISITING MEDICAL STUDENT AND MEDICAL GRAUDATE ROTATION REQUEST FORM

Welcome to Guthrie's Medical Education Department. This form is to be used by Medical School Graduates, non-GCSOM and LECOM Longitudinal M3 and M4 students to request rotations at Guthrie.

Date of this Request:

mm/dd/yyyy

Student's Last Name:

Please enter your last name:

Student's First Name:

Please enter your last name.

Student's Email Address:

Student's Phone Number:

Name of School/Program:

Please provide the name of your medical school.

Educational Affiliate's Contact Email Address

Medical Students, please provide the school's placement contact person's email address.

MEDICAL GRADUATES ONLY: NAME OF GUTHRIE PRECEPTOR

Medical Graduates should enter their sponsoring Guthrie Provider Preceptor's Name.

Preceptor's Email Address:

Provide this email address if you have already consulted with a Guthrie physician for precepting your rotaiton.

TRAINING LEVEL:

Please use the drop down menu to select your training level.

ROTATION SPECIALTY:

Please use the drop down menu to identify the specialty of the requested rotation.

CURRICULUM REQUIRES OPERATING ROOM EXPERIENCE?

Please use the drop down menu to indicate if an OR experience is required as part of this rotation.

IF OR EXPERIENCE REQUIRED - TYPE?

Please use the drop down menu to identify the curriculum required type of OR experience.

Rotation Site:

Please identify the Guthrie entity for this rotation.

Specific Site:

Please provide any additional information about the specific rotation site such as "Southern Tier Pediatrics."

Requested Rotation Start Date:

mm/dd/yyyy

Requested Rotation End Data:

mm/dd/yyyy

Send me a copy of my responses

Report Abuse