BROOKLYN USCE STANDARD PACKAGE FORM - TELEROTATIONS (DEPOSIT FORM)

BROOKLYN USCE STANDARD PACKAGE FORM (Tele- rotations)

DEPOSIT FEE
Name (As on Passport)*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Country/ Postal / Zip Code
Whatsapp number Country Code *
eg 1 (USA) or 91 (India)
Whatsapp Phone Number*
Please enter a 10 digit valid phone number.
Name of Medical school (Include city, state and Country) :*
Please select the rotation you are enrolling for:*

General IM (Telemedicine)Hematology-Oncology (Telemedicine)Nephrology (Telemedicine)Family Medicine (Telemedicine)Cardiology (Telemedicine)General IM 2 (Telemedicine)General IM 3 (Telemedicine)Endocrinology (Telemedicine)Rheumatology (Telemedicine)Pathology (Telemedicine)
Preferred Start Date: *

MonthDayYear
Please select Monday of the week
Email all documents mentioned below at Electives@BrooklynUSCE.com

We will require the following documents:

1. Valid passport and *USA visa.
2. Proof of medical school enrollment/graduation certificate.
3. Recent photo.
4. *Recent immunization records (PPD test within 12 months, MMR, TDaP, Hep B titers, or proof of vaccination. Influenza shot proof. )
5. USMLE exam score report (if any)
6. *Valid Health Insurance
7. HIPAA Certificate (https://www.hipaatraining.com/)
8. Infection Control Certificate (https://bit.ly/3nfXrsC)

*Please note: USA VISA, Immunization records, and valid health insurance is not required for telemedicine rotation.

All documents have to be emailed at least 2 weeks before the rotation start date. Failure to submit the documents will lead to the automatic cancellation of your rotation.

Rotation plan *

4 weeks rotation deposit fee Product Image

4 weeks rotation deposit fee Standard package can be postponed with a charge, but is not refundable and non-transferable. Please check terms and conditions for more information. The remaining balance of $1000 to be paid at least 2 weeks before the rotation start date.

$500.00

8 weeks rotation deposit fee Product Image

8 weeks rotation deposit fee Standard package can be postponed with a charge, but is not refundable and non-transferable. Please check terms and conditions for more information. The remaining balance of $1900 to be paid at least 2 weeks before the rotation start date.

$1,000.00

12 weeks rotation deposit fee Product Image

12 weeks rotation deposit fee Standard package can be postponed with a charge, but is not refundable and non-transferable. Please check terms and conditions for more information. The remaining balance of $2800 to be paid at least 2 weeks before the rotation start date.

$1,500.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

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BROOKLYN USCE STANDARD PACKAGE FORM (Tele- rotations)

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