Elective Rotation Application

Elective Rotation Application

Family Medicine: Direct Primary Care
Thank you for your interest in our clinic!

One quick note: there are some longer questions towards the bottom of this application. We encourage you to write those answers in a separate text editor / document and then copy and paste into this form. Any loss of internet connection or other 'blip' could cause you to lose those answers. We hate asking you to do work twice! Expect to hear back from us within 5 business days. If you have any questions, please reach out to our clinic manager, Fred, at fred@assurancehealth.org
Name*

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Email*
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Phone Number*
Please enter a valid phone number.
Residency Name*
Residency Location*
What year are you in Residency?*
What is your specialty?*
How long of a rotation would you prefer?*
What is your preferred start date for this rotation?*

MonthDayYear
Date
Are there any other dates that may work for your rotation with us? Share any pertinent information or requests here...
If selected, will you be in need of housing during your rotation with us?*

Yes, I need housing.No, I have a place to stay.I'm not sure yet.
If you are in possible need of housing, will you be traveling with family? Share any other details that will help us (number of family members + ages of children, etc.)
Are there any special notes you'd like to share with us about your potential housing or transportation needs?
What do you hope to learn and experience during this rotation? In other words, how can we make sure this experience will meet your personal needs as it relates to your future as a practicing physician? Please share in 300 words or less.*

0/300
Are you familiar with Direct Primary Care (DPC)?*

Yes, and I plan on pursuing options in DPC after residencyYes, but I'm not sure if it's the right fit for me yetI've heard of it, but am interested in learning moreNo, I haven't heard of DPC
In 300 words or less, tell us about your current picture of your ideal practice once graduating from residency.*

0/300
In 300 words or less, tells us about the most and least enjoyable aspects about working in the medical field for you personally.*
Knowing what we do now about COVID-19, what would you have done differently, if anything, at the primary care level during the height of the COVID-19 pandemic? Please share in 500 words or less.*

0/500
Is there anything else you'd like to share with us?
By clicking the submit button below, I acknowledge and agree that none of the above information is considered PHI (protected health information) and consent to have the above information transmitted through the Assurance Healthcare & Counseling Center email service, which is not encrypted, but as secure as email can be these days.
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Elective Rotation Application

Thank you for your interest in our clinic!