Physician Interest Form
Hello! Thanks for your interest in Harper Health. We are always interested in meeting primary care physicians with like-minded patient care philosophies. Please fill out the following form, and we will reach out if we think there might be a mutual fit.
Section 1: Basic Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
City and State of Residence
Are you legally authorized to work in the United States?
Yes
No
Section 2: Professional Credentials and Experience
Medical School Attended
Residency Program Attended
Board Certification(s) (Internal Medicine, Family Medicine, etc.)
Medical License(s) Held (State and License Number)
Are you currently in good standing with all licensing boards?
Yes
No
How many years have you been practicing primary care post-residency?
Section 3: Logistics
Which location(s) are you interested in?
Hinsdale, IL
Glenview, IL
Chicago (Streeterville), IL
Naples, FL
Sarasota, FL
Nashville, TN
Dallas, TX
Other
When would you be available to start?
-
Month
-
Day
Year
Date
Do you have any non-competes? If so, please describe.
Section 4: Resume and Additional Comments
Resume
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