CLINICAL PRECEPTORSHIP APPLICATIONLyons Primary Care Group offers exceptional care while providing preceptorship opportunities. Submit your application to be considered. Name * First Name Last Name Email * Phone * (###) ### #### Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What semester are you interested in completing clinical rotations? * Spring Semester Summer Semester Fall Semester Which days of the week will you be available for rotations? * Monday Tuesday Wednesday Thursday Friday Hours Required * Clinical Rotation Start Date * List an estimated starting date for your rotations. MM DD YYYY Clinical Rotation End Date * List an estimated end date for your rotations. MM DD YYYY How did you hear about us? * Word-of-mouth (ie, friend, family, or colleague) Online search (ie, Google) Social media platform (ie, Instagram, Facebook) Health care website (ie, Healthgrades, Zocdoc) Other source SCHOOL INFORMATION School Name * Clinical Program * Projected Graduation Date * List an estimated graduation date for completing your NP or PA degree. MM DD YYYY School Coordinator's Name * School Coordinator's Title * School Coordinator's Phone * (###) ### #### School Coordinator's Email * Message * Include any additional details you would like our clinical coordinator to consider for this rotation request. Attestation * By submitting my application, I agree to uphold Lyons Primary Care Group's commitment to protecting patients and promoting a healthy environment. This includes: Being drug-free Being tobacco-free and nicotine-free Being fragrance-free (avoiding strongly scented colognes, perfumes, or other strongly scented products) Thank you for applying. Completing a full application is the first step in our process. Submitting an application does not guarantee placement. We will contact you within 10 business days about your application.
