ComEx Preceptor Application and Renewal

Required

Name*

Credential* (enter ND, MD, DO, NP, etc.) Please note: you must be an eligible provider in clinical practice to participate in the ComEx program.

Clinic/Organization Name

Address*

City, State Zipcode*

Phone*

Email*

Website

Medical or Health Profession School Attended*

Degree*

Year Graduated*

License Number*

State of Licensure*

Years in Practice*

Malpractice Insurance

Do you have malpractice insurance coverage?*
Yes, I am coveredNo, I am not covered

Note: If you do not hold a license (practicing in an unlicensed state) or do not have malpractice coverage, our student may only observe you in practice and may not participate in patient care (they many not have physical contact with patients).

Name of Student requesting preceptorship (if applicable).

Tell us about your practice and what you expect from your students.

What is your practice focus, area of specialty, or major modalities used in your practice?*

Your requirements for students (class level, training, interests, attire, student interview, etc.)*

Available Days (optional – we are aware that many of you have changing schedules.)
Monday MorningMonday AfternoonTuesday MorningTuesday AfternoonWednesday MorningWednesday AfternoonThursday MorningThursday AfternoonFriday MorningFriday AfternoonSaturday MorningSaturday Afternoon

Read the Preceptor Agreement*

I have read the Preceptor Agreement and agree to the Preceptor Responsibilities. Yes

Site Visit

You will be contacted by the Clinical Education Coordinator to schedule a site visit or complete a Site Information form.

Read about the Benefits to ComEx Preceptors