Clinical Placement Request Form

Clinical Placement Request Form

Please complete this form to apply to our clinical preceptorship program request a clinical rotation at our medical practice. Our Medical Director will review your request to ensure that we are able to accommodate your program requirements. Typical response time is two business days. If you require assistance sooner, please contact our office at (617) 991-9151
📍 Current Location Through July 2025
275 Turnpike Street, Suite 206
Canton, MA 02021

📍New Location: August 2025
1391 Main Street, Unit B
Walpole, MA 02081

🔗 Learn more about our clinical preceptorship program:

www.aspiremedgroup.com/pmhnp-preceptorship-program
Student Name*

First Last
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Enter the best phone number to reach you
Email *
example@example.com
University/College *
Semester /Academic Year Requested *
(e.g. Fall 2025)
Number of Clinical Hours Requested*

≤ 100 hours: $1000 ($500 deposit)101 - 175 hours: $1500 ($750 deposit)176 - 250 hours: $2000 ($1000 deposit)≥ 251 hours: $2500 ($1250 deposit)
Professional Licensure*

Registered NurseNurse Practitioner
Availability (Days and Times)*
e.g. Monday 9 am - 5 pm, Thursday 11-7 pm
Professional License*

e.g. Massachusetts RN license
Cancelof
Resume/CV*

Cancelof
Preceptorship Program Financial Agreement
Please read carefully before signing below:
- I agree to remit a non-refundable deposit equal to 50% of the total program cost upon clinical site approval.
- The remaining balance is due in full on the first day of clinical training.
- Payments made via Credit Card, Debit Card, or Venmo will incur a 3% convenience fee.
- Payments made via Apple Pay, Check, Cash, or Zelle will not incur additional fees.
Agreement Confirmation*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: