Candidate Intake Form
Candidate Information
FULL Name
*
Specialty
*
Current Address
*
Cell Phone Number
*
Format: (000) 000-0000.
Current Base Salary
*
Current Email Address
*
example@example.com
Date Available to Start
*
/
Month
/
Day
Year
Date
Site Visit Availability
*
Additional Information about the candidate and current status
Physician Profile
Medical Degree
MD
DO
Other
Board Certification
B/C
B/E
B/E Specialty
B/E Expected
Fellowship Trained
Yes
No
If yes, Specialty
NPI
*
Additional Training and Skills
Describe any special training for this position
Do you have any entries in the National Healthcare Practitioner data bank?
Yes
No
If yes, please explain
Have you ever had your privileges terminated or denied?
Yes
No
If yes, please explain
Has there ever been disciplined by a medical board and/or a restriction placed on your medical license?
Yes
No If yes, please explain:
No If yes, please explain
Do you have any malpractice experiences?
Yes
No
If yes, please explain
Any cases settled?
Yes
No
If yes, please explain
Citizenship Status?
US Citizen
Green Card
H-1B Visa
J-1Visa
Other:
Immigration assistance required?
Yes
No
Foreign Languages Spoken
Additional Information
Search Questions
1.Is your search confidential?
*
Yes
No
2.What type of permanent position are you looking for (check all that applies)
Employed
Hospital Based Practice
Multi-Specialty Group
Single Specialty Group
Solo/Private Practice
3.
W
hat are your areas of interest in East Florida?
Please list relocation options by preference:
1.
2.
3.
4.
4.Do you have any ties to the above areas?
5. Are there any family considerations?
Desired Practice Situation
Desired Compensation
*
Call Preference
Comments
What makes this candidate stand out among other potential candidates?
Submit
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