www.clinicalmatchme.com
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2606:4700:3031::ac43:b613
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Submitted URL: https://8srn4k76.r.us-east-1.awstrack.me/L0/https:%2F%2Fb.clinicalmatchme.com%2FemailClick%2F616c6c656e2e776f6e674061752e626e707061726962...
Effective URL: https://www.clinicalmatchme.com/become-a-preceptor/?register
Submission: On August 20 via manual from IN — Scanned from US
Effective URL: https://www.clinicalmatchme.com/become-a-preceptor/?register
Submission: On August 20 via manual from IN — Scanned from US
Form analysis 2 forms found in the DOM
POST /become-a-preceptor/?register#quform-dc5b77
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name="form_url" value="https://www.clinicalmatchme.com/become-a-preceptor/?register"><input type="hidden" name="referring_url" value=""><input type="hidden" name="post_id" value="2774"><input type="hidden" name="post_title"
value="Become a preceptor"><input type="hidden" name="quform_current_page_id" value="1">
<div class="quform-form-title-description">
<p class="quform-form-description"></p>
<div style="margin: auto;text-align:center">
<div><img src="/app/images/cmm_logo_website.png"></div>
<h1>FREE Signup</h1>
</div>
<p></p>
</div>
<div class="quform-elements quform-elements-1 quform-cf quform-responsive-elements-phone-landscape">
<div class="quform-element quform-element-page quform-page-1 quform-page-1_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page">
<div class="quform-child-elements">
<div class="quform-element quform-element-radio quform-element-1_3 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_3"><label class="quform-label-text" id="quform_1_3_dc5b77_label">Are you registering as a student, a preceptor/attending, or a Medical Practice?</label></div>
<div class="quform-inner quform-inner-radio quform-inner-1_3">
<div class="quform-input quform-input-radio quform-input-1_3 quform-cf">
<div class="quform-options quform-cf quform-options-columns quform-3-columns quform-responsive-columns-phone-landscape quform-options-style-input-hidden" role="radiogroup" aria-labelledby="quform_1_3_dc5b77_label">
<div class="quform-option"><input type="radio" name="quform_1_3" id="quform_1_3_dc5b77_1" class="quform-field quform-field-radio quform-field-1_3 quform-field-1_3_1" value="1" checked=""><label for="quform_1_3_dc5b77_1"
class="quform-option-label quform-option-label-1_3_1"><span class="quform-option-icon-selected"><i class="fa fa-check-circle"></i></span><span class="quform-option-text"><i class="fas fa-user-graduate"></i>
Student</span></label></div>
<div class="quform-option"><input type="radio" name="quform_1_3" id="quform_1_3_dc5b77_2" class="quform-field quform-field-radio quform-field-1_3 quform-field-1_3_2" value="3"><label for="quform_1_3_dc5b77_2"
class="quform-option-label quform-option-label-1_3_2"><span class="quform-option-icon-selected"><i class="fa fa-check-circle"></i></span><span class="quform-option-text"><i class="fas fa-user-md"></i> Preceptor or
Attending</span></label></div>
<div class="quform-option"><input type="radio" name="quform_1_3" id="quform_1_3_dc5b77_3" class="quform-field quform-field-radio quform-field-1_3 quform-field-1_3_3" value="4"><label for="quform_1_3_dc5b77_3"
class="quform-option-label quform-option-label-1_3_3"><span class="quform-option-icon-selected"><i class="fa fa-check-circle"></i></span><span class="quform-option-text"><i class="fas fa-hospital"></i> Medical
Practice</span></label></div>
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</div>
</div>
</div>
</div>
<div class="quform-element quform-element-name quform-element-1_4 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_4"><label class="quform-label-text" id="quform_1_4_dc5b77_label">Name</label></div>
<div class="quform-inner quform-inner-name quform-inner-1_4">
<div class="quform-input quform-input-name quform-input-1_4 quform-cf">
<div class="quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element-column">
<div class="quform-element quform-element-text quform-element-1_4_2 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-inner quform-inner-text quform-inner-1_4_2">
<div class="quform-input quform-input-text quform-input-1_4_2 quform-cf"><input type="text" id="quform_1_4_2_dc5b77" name="quform_1_4[2]" class="quform-field quform-field-text quform-field-1_4_2"
aria-labelledby="quform_1_4_dc5b77_label quform_1_4_2_dc5b77_sub_label_below"></div><label id="quform_1_4_2_dc5b77_sub_label_below" class="quform-sub-label quform-sub-label-below">First</label>
</div>
</div>
</div>
</div>
<div class="quform-element-column">
<div class="quform-element quform-element-text quform-element-1_4_4 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-inner quform-inner-text quform-inner-1_4_4">
<div class="quform-input quform-input-text quform-input-1_4_4 quform-cf"><input type="text" id="quform_1_4_4_dc5b77" name="quform_1_4[4]" class="quform-field quform-field-text quform-field-1_4_4"
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</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-text quform-element-1_5 quform-cf quform-element-required" style="display: none;">
<div class="quform-spacer">
<div class="quform-label quform-label-1_5"><label class="quform-label-text" for="quform_1_5_dc5b77">Company</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_5">
<div class="quform-input quform-input-text quform-input-1_5 quform-cf"><input type="text" id="quform_1_5_dc5b77" name="quform_1_5" class="quform-field quform-field-text quform-field-1_5"></div>
</div>
</div>
</div>
<div class="quform-element quform-element-row quform-element-row-1_27 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_28">
<div class="quform-element quform-element-text quform-element-1_31 quform-cf quform-element-required" style="display: none;">
<div class="quform-spacer">
<div class="quform-label quform-label-1_31"><span class="quform-label-icon"><i class="fal fa-phone"></i></span><label class="quform-label-text" for="quform_1_31_dc5b77">Office Phone</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_31">
<div class="quform-input quform-input-text quform-input-1_31 quform-cf"><input type="text" id="quform_1_31_dc5b77" name="quform_1_31" class="quform-field quform-field-text quform-field-1_31"></div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-column quform-element-1_29">
<div class="quform-element quform-element-text quform-element-1_32 quform-cf quform-element-optional" style="display: none;">
<div class="quform-spacer">
<div class="quform-label quform-label-1_32"><label class="quform-label-text" for="quform_1_32_dc5b77">Extension</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_32">
<div class="quform-input quform-input-text quform-input-1_32 quform-cf"><input type="text" id="quform_1_32_dc5b77" name="quform_1_32" class="quform-field quform-field-text quform-field-1_32"></div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-row quform-element-row-1_8 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_9">
<div class="quform-element quform-element-email quform-element-1_6 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_6"><span class="quform-label-icon"><i class="fal fa-envelope"></i></span><label class="quform-label-text" for="quform_1_6_dc5b77">Email address</label></div>
<div class="quform-inner quform-inner-email quform-inner-1_6">
<div class="quform-input quform-input-email quform-input-1_6 quform-cf"><input type="email" id="quform_1_6_dc5b77" name="quform_1_6" class="quform-field quform-field-email quform-field-1_6"></div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-column quform-element-1_10">
<div class="quform-element quform-element-text quform-element-1_7 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_7"><span class="quform-label-icon"><i class="fal fa-mobile"></i></span><label class="quform-label-text" for="quform_1_7_dc5b77">Mobile Phone</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_7">
<div class="quform-input quform-input-text quform-input-1_7 quform-cf"><input type="text" id="quform_1_7_dc5b77" name="quform_1_7" class="quform-field quform-field-text quform-field-1_7"></div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-row quform-element-row-1_12 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_13">
<div class="quform-element quform-element-text quform-element-1_17 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_17"><label class="quform-label-text" for="quform_1_17_dc5b77">City</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_17">
<div class="quform-input quform-input-text quform-input-1_17 quform-cf"><input type="text" id="quform_1_17_dc5b77" name="quform_1_17" class="quform-field quform-field-text quform-field-1_17"></div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-column quform-element-1_15">
<div class="quform-element quform-element-select quform-element-1_18 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_18"><label class="quform-label-text" for="quform_1_18_dc5b77">State</label></div>
<div class="quform-inner quform-inner-select quform-inner-1_18">
<div class="quform-input quform-input-select quform-input-1_18 quform-cf"><select id="quform_1_18_dc5b77" name="quform_1_18" class="quform-field quform-field-select quform-field-1_18">
<option value="" selected="selected">Please select</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select></div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-row quform-element-row-1_23 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_24">
<div class="quform-element quform-element-password quform-element-1_22 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_22"><label class="quform-label-text" for="quform_1_22_dc5b77">Password</label></div>
<div class="quform-inner quform-inner-password quform-inner-1_22">
<div class="quform-input quform-input-password quform-input-1_22 quform-cf"><input type="password" id="quform_1_22_dc5b77" name="quform_1_22" class="quform-field quform-field-password quform-field-1_22"></div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-column quform-element-1_25">
<div class="quform-element quform-element-password quform-element-1_26 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_26"><label class="quform-label-text" for="quform_1_26_dc5b77">Password Confirmation</label></div>
<div class="quform-inner quform-inner-password quform-inner-1_26">
<div class="quform-input quform-input-password quform-input-1_26 quform-cf"><input type="password" id="quform_1_26_dc5b77" name="quform_1_26" class="quform-field quform-field-password quform-field-1_26"></div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-row quform-element-row-1_79 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_80">
<div class="quform-element quform-element-radio quform-element-1_47 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_47"><label class="quform-label-text" id="quform_1_47_dc5b77_label">Gender</label></div>
<div class="quform-inner quform-inner-radio quform-inner-1_47">
<div class="quform-input quform-input-radio quform-input-1_47 quform-cf">
<div class="quform-options quform-cf quform-options-inline quform-options-style-button quform-button-style-bootstrap quform-button-icon-left" role="radiogroup" aria-labelledby="quform_1_47_dc5b77_label">
<div class="quform-option"><input type="radio" name="quform_1_47" id="quform_1_47_dc5b77_1" class="quform-field quform-field-radio quform-field-1_47 quform-field-1_47_1" value="Male"><label for="quform_1_47_dc5b77_1"
class="quform-option-label quform-option-label-1_47_1"><span class="quform-option-text">Male</span></label></div>
<div class="quform-option"><input type="radio" name="quform_1_47" id="quform_1_47_dc5b77_2" class="quform-field quform-field-radio quform-field-1_47 quform-field-1_47_2" value="Female"><label for="quform_1_47_dc5b77_2"
class="quform-option-label quform-option-label-1_47_2"><span class="quform-option-text">Female</span></label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-group quform-element-1_39 quform-cf quform-group-style-plain">
<div class="quform-spacer">
<div class="quform-group-title-description">
<h3 class="quform-group-title">Professional Information</h3>
</div>
<div class="quform-child-elements">
<div class="quform-element quform-element-row quform-element-row-1_88 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_89">
<div class="quform-element quform-element-row quform-element-row-1_92 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_93">
<div class="quform-element quform-element-text quform-element-1_91 quform-cf quform-element-optional">
<div class="quform-spacer">
<div class="quform-label quform-label-1_91"><label class="quform-label-text" for="quform_1_91_dc5b77">NPI No</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_91">
<div class="quform-input quform-input-text quform-input-1_91 quform-cf"><input type="text" id="quform_1_91_dc5b77" name="quform_1_91" class="quform-field quform-field-text quform-field-1_91"></div>
<p class="quform-description quform-description-below">If you have an NPI number, enter it here. If not, leave this blank.</p>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-column quform-element-1_94">
<div class="quform-element quform-element-select quform-element-1_35 quform-cf quform-element-optional">
<div class="quform-spacer">
<div class="quform-label quform-label-1_35"><label class="quform-label-text" for="quform_1_35_dc5b77">Degree</label></div>
<div class="quform-inner quform-inner-select quform-inner-1_35">
<div class="quform-input quform-input-select quform-input-1_35 quform-cf"><select id="quform_1_35_dc5b77" name="quform_1_35" class="quform-field quform-field-select quform-field-1_35">
<option value="3">APRN</option>
<option value="6">BA / BS</option>
<option value="27">BCBA</option>
<option value="5">CNM</option>
<option value="24">CNS</option>
<option value="14">CPM</option>
<option value="10">DNP</option>
<option value="2">DO</option>
<option value="15">FNP</option>
<option value="29">LAPSW</option>
<option value="19">LCSW</option>
<option value="31">LICSW</option>
<option value="30">LMFT</option>
<option value="18">LMHC</option>
<option value="17">LMSC</option>
<option value="12">LMSW</option>
<option value="16">LPC</option>
<option value="26">LPCC</option>
<option value="1">MD</option>
<option value="28">MSW</option>
<option value="23">OMD</option>
<option value="4">PA</option>
<option value="25">Ph.D</option>
<option value="11">PMHNP</option>
<option value="13">PNP</option>
<option value="7">PsyD</option>
<option value="8" selected="selected">RN</option>
<option value="22">SAP</option>
<option value="32">WHNP</option>
</select></div>
<p class="quform-description quform-description-below">Please select your <strong>CURRENT</strong> health care degree. For example, if you are in school to become an APRN, your <strong>CURRENT</strong> degree is probably
<strong>RN</strong>.</p>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-text quform-element-1_106 quform-cf quform-element-optional" style="display: none;">
<div class="quform-spacer">
<div class="quform-label quform-label-1_106"><label class="quform-label-text" for="quform_1_106_dc5b77">Facility NPI No</label></div>
<div class="quform-inner quform-inner-text quform-inner-1_106">
<div class="quform-input quform-input-text quform-input-1_106 quform-cf"><input type="text" id="quform_1_106_dc5b77" name="quform_1_106" class="quform-field quform-field-text quform-field-1_106"></div>
<p class="quform-description quform-description-below">If you're affiliated with a medical practice, clinic or hospital, please enter the facility's NPI number. This is different from your personal NPI number. If you're not
affiliated with a facility, or you don't know its NPI number, you may leave this blank.</p>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-checkbox quform-element-1_38 quform-cf quform-element-required" style="display: none;">
<div class="quform-spacer">
<div class="quform-label quform-label-1_38"><label class="quform-label-text" id="quform_1_38_dc5b77_label">Which specialties can you offer training in?</label></div>
<div class="quform-inner quform-inner-checkbox quform-inner-1_38"><label id="quform_1_38_dc5b77_sub_label_above" class="quform-sub-label quform-sub-label-above">If you offer telepsych, but require students to be physically present
during telepsych sessions, please select <em>In Person</em>. If you allow students to connect to telepsych sessions remotely, select <em>Remote Student</em>. If you allow both In Person and Remote Student, please select both
specialties.</label>
<div class="quform-input quform-input-checkbox quform-input-1_38 quform-cf">
<div class="quform-options quform-cf quform-options-columns quform-3-columns quform-responsive-columns-phone-landscape quform-options-simple" role="group" aria-labelledby="quform_1_38_dc5b77_label">
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_59" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_59" value="59"><label
for="quform_1_38_dc5b77_59" class="quform-option-label quform-option-label-1_38_59"><span class="quform-option-text">Acupuncturist & Herbalist</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_77" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_77" value="77"><label
for="quform_1_38_dc5b77_77" class="quform-option-label quform-option-label-1_38_77"><span class="quform-option-text">Acute Care in an Urgent Care setting in an Inpatient setting</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_37" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_37" value="37"><label
for="quform_1_38_dc5b77_37" class="quform-option-label quform-option-label-1_38_37"><span class="quform-option-text">Acute Care in an Urgent Care setting in an outpatient setting</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_40" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_40" value="40"><label
for="quform_1_38_dc5b77_40" class="quform-option-label quform-option-label-1_38_40"><span class="quform-option-text">Addiction Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_22" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_22" value="22"><label
for="quform_1_38_dc5b77_22" class="quform-option-label quform-option-label-1_38_22"><span class="quform-option-text">Adult Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_9" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_9" value="9"><label for="quform_1_38_dc5b77_9"
class="quform-option-label quform-option-label-1_38_9"><span class="quform-option-text">Advanced Assessment</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_23" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_23" value="23"><label
for="quform_1_38_dc5b77_23" class="quform-option-label quform-option-label-1_38_23"><span class="quform-option-text">Allergy</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_52" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_52" value="52"><label
for="quform_1_38_dc5b77_52" class="quform-option-label quform-option-label-1_38_52"><span class="quform-option-text">Anesthesiology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_47" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_47" value="47"><label
for="quform_1_38_dc5b77_47" class="quform-option-label quform-option-label-1_38_47"><span class="quform-option-text">Anti Age, Medical Spa, Weight loss, Aesthetics</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_15" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_15" value="15"><label
for="quform_1_38_dc5b77_15" class="quform-option-label quform-option-label-1_38_15"><span class="quform-option-text">Cardiology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_68" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_68" value="68"><label
for="quform_1_38_dc5b77_68" class="quform-option-label quform-option-label-1_38_68"><span class="quform-option-text">CNO, Chief Nursing Officer</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_14" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_14" value="14"><label
for="quform_1_38_dc5b77_14" class="quform-option-label quform-option-label-1_38_14"><span class="quform-option-text">Dermatology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_65" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_65" value="65"><label
for="quform_1_38_dc5b77_65" class="quform-option-label quform-option-label-1_38_65"><span class="quform-option-text">Doctorate Thesis Advisor / Scholarly Advisor</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_27" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_27" value="27"><label
for="quform_1_38_dc5b77_27" class="quform-option-label quform-option-label-1_38_27"><span class="quform-option-text">Education specialist based in a hospital</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_6" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_6" value="6"><label for="quform_1_38_dc5b77_6"
class="quform-option-label quform-option-label-1_38_6"><span class="quform-option-text">Emergency Medicine / Adult or Pediatric / ER</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_46" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_46" value="46"><label
for="quform_1_38_dc5b77_46" class="quform-option-label quform-option-label-1_38_46"><span class="quform-option-text">Endocrinology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_45" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_45" value="45"><label
for="quform_1_38_dc5b77_45" class="quform-option-label quform-option-label-1_38_45"><span class="quform-option-text">Endoscopy</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_25" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_25" value="25"><label
for="quform_1_38_dc5b77_25" class="quform-option-label quform-option-label-1_38_25"><span class="quform-option-text">ENT</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_1" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_1" value="1"><label for="quform_1_38_dc5b77_1"
class="quform-option-label quform-option-label-1_38_1"><span class="quform-option-text">Family medicine or Primary Care</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_21" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_21" value="21"><label
for="quform_1_38_dc5b77_21" class="quform-option-label quform-option-label-1_38_21"><span class="quform-option-text">Gastroenterology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_76" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_76" value="76"><label
for="quform_1_38_dc5b77_76" class="quform-option-label quform-option-label-1_38_76"><span class="quform-option-text">Genetics</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_4" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_4" value="4"><label for="quform_1_38_dc5b77_4"
class="quform-option-label quform-option-label-1_38_4"><span class="quform-option-text">Geriatric Medicine / Elder Care</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_5" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_5" value="5"><label for="quform_1_38_dc5b77_5"
class="quform-option-label quform-option-label-1_38_5"><span class="quform-option-text">Gynecology (GYN)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_73" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_73" value="73"><label
for="quform_1_38_dc5b77_73" class="quform-option-label quform-option-label-1_38_73"><span class="quform-option-text">Gynecology specializing in Fertility and Reproductive medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_66" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_66" value="66"><label
for="quform_1_38_dc5b77_66" class="quform-option-label quform-option-label-1_38_66"><span class="quform-option-text">Gynecology with Obstetrics (OB/GYN)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_38" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_38" value="38"><label
for="quform_1_38_dc5b77_38" class="quform-option-label quform-option-label-1_38_38"><span class="quform-option-text">Hospice</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_2" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_2" value="2"><label for="quform_1_38_dc5b77_2"
class="quform-option-label quform-option-label-1_38_2"><span class="quform-option-text">Hospital Based Care</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_12" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_12" value="12"><label
for="quform_1_38_dc5b77_12" class="quform-option-label quform-option-label-1_38_12"><span class="quform-option-text">Hospitalist</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_63" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_63" value="63"><label
for="quform_1_38_dc5b77_63" class="quform-option-label quform-option-label-1_38_63"><span class="quform-option-text">Indian Health Services</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_29" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_29" value="29"><label
for="quform_1_38_dc5b77_29" class="quform-option-label quform-option-label-1_38_29"><span class="quform-option-text">Infectious Disease</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_44" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_44" value="44"><label
for="quform_1_38_dc5b77_44" class="quform-option-label quform-option-label-1_38_44"><span class="quform-option-text">Intensivist</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_13" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_13" value="13"><label
for="quform_1_38_dc5b77_13" class="quform-option-label quform-option-label-1_38_13"><span class="quform-option-text">Internal Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_7" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_7" value="7"><label for="quform_1_38_dc5b77_7"
class="quform-option-label quform-option-label-1_38_7"><span class="quform-option-text">Leadership and Management C-suite level mentor</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_71" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_71" value="71"><label
for="quform_1_38_dc5b77_71" class="quform-option-label quform-option-label-1_38_71"><span class="quform-option-text">Medical Assistant Office Based</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_74" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_74" value="74"><label
for="quform_1_38_dc5b77_74" class="quform-option-label quform-option-label-1_38_74"><span class="quform-option-text">Medical Science Liaison</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_57" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_57" value="57"><label
for="quform_1_38_dc5b77_57" class="quform-option-label quform-option-label-1_38_57"><span class="quform-option-text">Natural and Holistic Family Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_72" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_72" value="72"><label
for="quform_1_38_dc5b77_72" class="quform-option-label quform-option-label-1_38_72"><span class="quform-option-text">Neonatal / Pediatric ICU</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_48" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_48" value="48"><label
for="quform_1_38_dc5b77_48" class="quform-option-label quform-option-label-1_38_48"><span class="quform-option-text">Nephrology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_17" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_17" value="17"><label
for="quform_1_38_dc5b77_17" class="quform-option-label quform-option-label-1_38_17"><span class="quform-option-text">Neurology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_70" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_70" value="70"><label
for="quform_1_38_dc5b77_70" class="quform-option-label quform-option-label-1_38_70"><span class="quform-option-text">Nursing Hospital Based</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_54" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_54" value="54"><label
for="quform_1_38_dc5b77_54" class="quform-option-label quform-option-label-1_38_54"><span class="quform-option-text">Nursing Informatics</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_69" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_69" value="69"><label
for="quform_1_38_dc5b77_69" class="quform-option-label quform-option-label-1_38_69"><span class="quform-option-text">Nursing Office Based</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_67" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_67" value="67"><label
for="quform_1_38_dc5b77_67" class="quform-option-label quform-option-label-1_38_67"><span class="quform-option-text">Obstetrics</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_43" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_43" value="43"><label
for="quform_1_38_dc5b77_43" class="quform-option-label quform-option-label-1_38_43"><span class="quform-option-text">Occupational Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_30" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_30" value="30"><label
for="quform_1_38_dc5b77_30" class="quform-option-label quform-option-label-1_38_30"><span class="quform-option-text">Oncology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_33" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_33" value="33"><label
for="quform_1_38_dc5b77_33" class="quform-option-label quform-option-label-1_38_33"><span class="quform-option-text">Ophthalmology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_51" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_51" value="51"><label
for="quform_1_38_dc5b77_51" class="quform-option-label quform-option-label-1_38_51"><span class="quform-option-text">Osteopathic Manipulative Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_31" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_31" value="31"><label
for="quform_1_38_dc5b77_31" class="quform-option-label quform-option-label-1_38_31"><span class="quform-option-text">Pain Management</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_39" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_39" value="39"><label
for="quform_1_38_dc5b77_39" class="quform-option-label quform-option-label-1_38_39"><span class="quform-option-text">Palliative care</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_3" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_3" value="3"><label for="quform_1_38_dc5b77_3"
class="quform-option-label quform-option-label-1_38_3"><span class="quform-option-text">Pediatrics</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_50" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_50" value="50"><label
for="quform_1_38_dc5b77_50" class="quform-option-label quform-option-label-1_38_50"><span class="quform-option-text">Physiatrist</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_8" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_8" value="8"><label for="quform_1_38_dc5b77_8"
class="quform-option-label quform-option-label-1_38_8"><span class="quform-option-text">Psychiatry (in person, Discuss patient mix with student)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_34" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_34" value="34"><label
for="quform_1_38_dc5b77_34" class="quform-option-label quform-option-label-1_38_34"><span class="quform-option-text">Psychiatry (remote, discuss patient mix with student)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_28" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_28" value="28"><label
for="quform_1_38_dc5b77_28" class="quform-option-label quform-option-label-1_38_28"><span class="quform-option-text">Psychiatry - Child and Adolescent (in person)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_42" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_42" value="42"><label
for="quform_1_38_dc5b77_42" class="quform-option-label quform-option-label-1_38_42"><span class="quform-option-text">Psychiatry - Child and Adolescent (remote student)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_75" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_75" value="75"><label
for="quform_1_38_dc5b77_75" class="quform-option-label quform-option-label-1_38_75"><span class="quform-option-text">Psychiatry - Inpatient in a Hospital setting (ask specificaly what population is being
served)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_10" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_10" value="10"><label
for="quform_1_38_dc5b77_10" class="quform-option-label quform-option-label-1_38_10"><span class="quform-option-text">Psychology / Psychotherapy (in person)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_35" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_35" value="35"><label
for="quform_1_38_dc5b77_35" class="quform-option-label quform-option-label-1_38_35"><span class="quform-option-text">Psychology / Psychotherapy (remote student)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_56" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_56" value="56"><label
for="quform_1_38_dc5b77_56" class="quform-option-label quform-option-label-1_38_56"><span class="quform-option-text">Psychology/ Psychotherapy - Child and Adolescent (in person)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_55" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_55" value="55"><label
for="quform_1_38_dc5b77_55" class="quform-option-label quform-option-label-1_38_55"><span class="quform-option-text">Psychology/ Psychotherapy - Child and Adolescent (remote student)</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_20" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_20" value="20"><label
for="quform_1_38_dc5b77_20" class="quform-option-label quform-option-label-1_38_20"><span class="quform-option-text">Pulmonary</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_32" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_32" value="32"><label
for="quform_1_38_dc5b77_32" class="quform-option-label quform-option-label-1_38_32"><span class="quform-option-text">Radiology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_62" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_62" value="62"><label
for="quform_1_38_dc5b77_62" class="quform-option-label quform-option-label-1_38_62"><span class="quform-option-text">Radiology Interventional</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_26" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_26" value="26"><label
for="quform_1_38_dc5b77_26" class="quform-option-label quform-option-label-1_38_26"><span class="quform-option-text">Research</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_61" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_61" value="61"><label
for="quform_1_38_dc5b77_61" class="quform-option-label quform-option-label-1_38_61"><span class="quform-option-text">Resident</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_64" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_64" value="64"><label
for="quform_1_38_dc5b77_64" class="quform-option-label quform-option-label-1_38_64"><span class="quform-option-text">Resident NP or PA</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_36" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_36" value="36"><label
for="quform_1_38_dc5b77_36" class="quform-option-label quform-option-label-1_38_36"><span class="quform-option-text">Rheumatology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_41" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_41" value="41"><label
for="quform_1_38_dc5b77_41" class="quform-option-label quform-option-label-1_38_41"><span class="quform-option-text">Sleep Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_60" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_60" value="60"><label
for="quform_1_38_dc5b77_60" class="quform-option-label quform-option-label-1_38_60"><span class="quform-option-text">Sports Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_53" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_53" value="53"><label
for="quform_1_38_dc5b77_53" class="quform-option-label quform-option-label-1_38_53"><span class="quform-option-text">Surgery Bariatric</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_19" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_19" value="19"><label
for="quform_1_38_dc5b77_19" class="quform-option-label quform-option-label-1_38_19"><span class="quform-option-text">Surgery General</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_24" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_24" value="24"><label
for="quform_1_38_dc5b77_24" class="quform-option-label quform-option-label-1_38_24"><span class="quform-option-text">Surgery Orthopedics</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_16" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_16" value="16"><label
for="quform_1_38_dc5b77_16" class="quform-option-label quform-option-label-1_38_16"><span class="quform-option-text">Surgery Plastic</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_58" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_58" value="58"><label
for="quform_1_38_dc5b77_58" class="quform-option-label quform-option-label-1_38_58"><span class="quform-option-text">Traditional Chinese Medicine</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_18" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_18" value="18"><label
for="quform_1_38_dc5b77_18" class="quform-option-label quform-option-label-1_38_18"><span class="quform-option-text">Urology</span></label></div>
<div class="quform-option"><input type="checkbox" name="quform_1_38[]" id="quform_1_38_dc5b77_49" class="quform-field quform-field-checkbox quform-field-1_38 quform-field-1_38_49" value="49"><label
for="quform_1_38_dc5b77_49" class="quform-option-label quform-option-label-1_38_49"><span class="quform-option-text">Wound Care</span></label></div>
</div>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-row quform-element-row-1_44 quform-2-columns quform-element-row-size-float quform-responsive-columns-phone-landscape">
<div class="quform-element quform-element-column quform-element-1_45">
<div class="quform-element quform-element-radio quform-element-1_42 quform-cf quform-element-required" style="display: none;">
<div class="quform-spacer">
<div class="quform-label quform-label-1_42"><label class="quform-label-text" id="quform_1_42_dc5b77_label">Will you accept male students for Women's Health?</label></div>
<div class="quform-inner quform-inner-radio quform-inner-1_42">
<div class="quform-input quform-input-radio quform-input-1_42 quform-cf">
<div class="quform-options quform-cf quform-options-inline quform-options-style-button quform-button-style-bootstrap quform-button-icon-left" role="radiogroup" aria-labelledby="quform_1_42_dc5b77_label">
<div class="quform-option"><input type="radio" name="quform_1_42" id="quform_1_42_dc5b77_1" class="quform-field quform-field-radio quform-field-1_42 quform-field-1_42_1" value="Yes"><label for="quform_1_42_dc5b77_1"
class="quform-option-label quform-option-label-1_42_1"><span class="quform-option-text">Yes</span></label></div>
<div class="quform-option"><input type="radio" name="quform_1_42" id="quform_1_42_dc5b77_2" class="quform-field quform-field-radio quform-field-1_42 quform-field-1_42_2" value="No"><label for="quform_1_42_dc5b77_2"
class="quform-option-label quform-option-label-1_42_2"><span class="quform-option-text">No</span></label></div>
</div>
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</div>
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<div class="quform-element quform-element-column quform-element-1_46"></div>
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<div class="quform-element quform-element-group quform-element-1_82 quform-cf quform-group-style-plain">
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<h3 class="quform-group-title">Educational Information</h3>
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<div class="quform-child-elements">
<div class="quform-element quform-element-row quform-element-row-1_83 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape">
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<div class="quform-element quform-element-select quform-element-1_86 quform-cf quform-element-required">
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<div class="quform-label quform-label-1_86"><label class="quform-label-text" for="quform_1_86_dc5b77">Curriculum</label></div>
<div class="quform-inner quform-inner-select quform-inner-1_86">
<div class="quform-input quform-input-select quform-input-1_86 quform-cf"><select id="quform_1_86_dc5b77" name="quform_1_86" class="quform-field quform-field-select quform-field-1_86">
<option value="">Please select</option>
<option value="1">NP Student</option>
<option value="2">PA Student</option>
<option value="5">Medical Student</option>
</select></div>
<p class="quform-description quform-description-below">Please select the curriculum you're currently enrolled in and seeking placement for.</p>
</div>
</div>
</div>
</div>
<div class="quform-element quform-element-column quform-element-1_85">
<div class="quform-element quform-element-select quform-element-1_77 quform-cf quform-element-required">
<div class="quform-spacer">
<div class="quform-label quform-label-1_77"><label class="quform-label-text" for="quform_1_77_dc5b77">School</label></div>
<div class="quform-inner quform-inner-select quform-inner-1_77">
<div class="quform-input quform-input-select quform-input-1_77 quform-cf"><select id="quform_1_77_dc5b77" name="quform_1_77" class="quform-field quform-field-select quform-field-1_77" disabled="disabled">
<option value="">Select your curriculum first</option>
</select></div>
<p class="quform-description quform-description-below">Please contact us if you don't see your school listed.</p>
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<div class="quform-option"><input type="checkbox" name="quform_1_33[]" id="quform_1_33_dc5b77_1" class="quform-field quform-field-checkbox quform-field-1_33 quform-field-1_33_1" value="1"><label for="quform_1_33_dc5b77_1"
class="quform-option-label quform-option-label-1_33_1"><span class="quform-option-text">I accept the <a href="/terms-of-service" target="_blank">Terms of Service</a> and
<a href="/privacy" target="_blank">Privacy Policy</a></span></label></div>
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<div class="quform-element quform-element-checkbox quform-element-1_107 quform-cf quform-element-optional" style="display: none;">
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<div class="quform-inner quform-inner-checkbox quform-inner-1_107">
<div class="quform-input quform-input-checkbox quform-input-1_107 quform-cf">
<div class="quform-options quform-cf quform-options-block quform-options-simple">
<div class="quform-option"><input type="checkbox" name="quform_1_107[]" id="quform_1_107_dc5b77_1" class="quform-field quform-field-checkbox quform-field-1_107 quform-field-1_107_1" value="1"><label for="quform_1_107_dc5b77_1"
class="quform-option-label quform-option-label-1_107_1"><span class="quform-option-text">I agree to receive NON-marketing SMS messages at the mobile phone number entered above. </span></label></div>
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<p class="quform-description quform-description-below">We send SMS messages to update you on the status of your preceptor placement requests and notify you when preceptors send you offers. We do NOT send marketing messages and we will
NEVER spam you. This is NOT required, but highly recommended, to ensure that you don't miss any offers or important updates. You can opt out at any time.</p>
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<div class="quform-element quform-element-checkbox quform-element-1_34 quform-cf quform-element-optional">
<div class="quform-spacer">
<div class="quform-inner quform-inner-checkbox quform-inner-1_34">
<div class="quform-input quform-input-checkbox quform-input-1_34 quform-cf">
<div class="quform-options quform-cf quform-options-block quform-options-simple">
<div class="quform-option"><input type="checkbox" name="quform_1_34[]" id="quform_1_34_dc5b77_1" class="quform-field quform-field-checkbox quform-field-1_34 quform-field-1_34_1" value="1"><label for="quform_1_34_dc5b77_1"
class="quform-option-label quform-option-label-1_34_1"><span class="quform-option-text">Enroll me in a FREE NP Nation Lite membership (optional)</span></label></div>
</div>
</div>
<p class="quform-description quform-description-below">NP Nation is a nationwide advocacy group and membership organization for nurse practitioners. NPN advocates for nurse practitioner rights and participated in campaigning for
independent practice. As an NPN member, you'll gain access to discounted malpractice insurance and we'll send you occasional email offers for relevant products and services. There's NO COST for the Lite membership and you may
opt-out at any time.</p>
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</div><input type="hidden" name="quform_1_96" class="quform-field quform-field-hidden quform-field-1_96" data-default="" value="600">
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<span class="bb-popup__time">Our time: 3:44am EDT</span>
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<ol>
<li class="bb-active" data-index="1">
<a href="#">1. Service & Date</a>
</li>
<li data-index="2">
<a href="#">2. Select Time Slot</a>
</li>
<li data-index="3">
<a href="#">3. Details/Payment</a>
</li>
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<a href="#">4. Confirmation</a>
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</nav><!-- /.bb-tabs__nav -->
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<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/flatpickr/dist/flatpickr.min.css">
<script src="https://cdn.jsdelivr.net/npm/flatpickr"></script>
<style type="text/css" media="screen">
.bb-section-service .flatpickr-calendar .flatpickr-months {
background: #01bae8;
}
.bb-section-service .flatpickr-calendar .flatpickr-day.selected {
background: #f55388;
color: #fff;
}
.bb-section-service .flatpickr-calendar .flatpickr-day:hover {
background: #f55388;
color: #fff;
}
</style>
<div class="bb-section-service">
<div class="bb-section__content">
<div class="bb-list-inputs">
<ul>
<li>
<div class="bb-form-controls">
<label style="color: #01bae8" for="bb-form-service-category"> Service </label>
<div class="bb-select">
<select name="bb-form-service" id="bb-form-service">
<option value="416"> Zoom Meeting </option>
</select>
</div><!-- /.bb-select -->
</div><!-- /.bb-form-controls -->
</li>
</ul>
</div><!-- /.bb-list-inputs -->
</div><!-- /.bb-section__content -->
<div class="bb-section__calendar">
<div class="bb-calendar flatpickr-input" readonly="readonly"></div>
<div class="flatpickr-calendar animate inline" tabindex="-1">
<div class="flatpickr-months"><span class="flatpickr-prev-month flatpickr-disabled"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" viewBox="0 0 17 17">
<g></g>
<path d="M5.207 8.471l7.146 7.147-0.707 0.707-7.853-7.854 7.854-7.853 0.707 0.707-7.147 7.146z"></path>
</svg></span>
<div class="flatpickr-month">
<div class="flatpickr-current-month"><select class="flatpickr-monthDropdown-months" aria-label="Month" tabindex="-1">
<option class="flatpickr-monthDropdown-month" value="7" tabindex="-1">August</option>
<option class="flatpickr-monthDropdown-month" value="8" tabindex="-1">September</option>
<option class="flatpickr-monthDropdown-month" value="9" tabindex="-1">October</option>
<option class="flatpickr-monthDropdown-month" value="10" tabindex="-1">November</option>
<option class="flatpickr-monthDropdown-month" value="11" tabindex="-1">December</option>
</select>
<div class="numInputWrapper"><input class="numInput cur-year" type="number" tabindex="-1" aria-label="Year" min="2024"><span class="arrowUp"></span><span class="arrowDown"></span></div>
</div>
</div><span class="flatpickr-next-month"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" viewBox="0 0 17 17">
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<path d="M13.207 8.472l-7.854 7.854-0.707-0.707 7.146-7.146-7.146-7.148 0.707-0.707 7.854 7.854z"></path>
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<div class="flatpickr-rContainer">
<div class="flatpickr-weekdays">
<div class="flatpickr-weekdaycontainer">
<span class="flatpickr-weekday"> Sun</span><span class="flatpickr-weekday">Mon</span><span class="flatpickr-weekday">Tue</span><span class="flatpickr-weekday">Wed</span><span class="flatpickr-weekday">Thu</span><span
class="flatpickr-weekday">Fri</span><span class="flatpickr-weekday">Sat </span>
</div>
</div>
<div class="flatpickr-days" tabindex="-1">
<div class="dayContainer"><span class="flatpickr-day prevMonthDay flatpickr-disabled" aria-label="July 28, 2024">28</span><span class="flatpickr-day prevMonthDay flatpickr-disabled" aria-label="July 29, 2024">29</span><span
class="flatpickr-day prevMonthDay flatpickr-disabled" aria-label="July 30, 2024">30</span><span class="flatpickr-day prevMonthDay flatpickr-disabled" aria-label="July 31, 2024">31</span><span
class="flatpickr-day flatpickr-disabled" aria-label="August 1, 2024">1</span><span class="flatpickr-day flatpickr-disabled" aria-label="August 2, 2024">2</span><span class="flatpickr-day flatpickr-disabled"
aria-label="August 3, 2024">3</span><span class="flatpickr-day flatpickr-disabled" aria-label="August 4, 2024">4</span><span class="flatpickr-day flatpickr-disabled" aria-label="August 5, 2024">5</span><span
class="flatpickr-day flatpickr-disabled" aria-label="August 6, 2024">6</span><span class="flatpickr-day flatpickr-disabled" aria-label="August 7, 2024">7</span><span class="flatpickr-day flatpickr-disabled"
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</form>Text Content
FREE SIGNUP Are you registering as a student, a preceptor/attending, or a Medical Practice? Student Preceptor or Attending Medical Practice Name First Last Company Office Phone Extension Email address Mobile Phone City State Please selectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Password Password Confirmation Gender Male Female PROFESSIONAL INFORMATION NPI No If you have an NPI number, enter it here. If not, leave this blank. Degree APRNBA / BSBCBACNMCNSCPMDNPDOFNPLAPSWLCSWLICSWLMFTLMHCLMSCLMSWLPCLPCCMDMSWOMDPAPh.DPMHNPPNPPsyDRNSAPWHNP Please select your CURRENT health care degree. For example, if you are in school to become an APRN, your CURRENT degree is probably RN. Facility NPI No If you're affiliated with a medical practice, clinic or hospital, please enter the facility's NPI number. This is different from your personal NPI number. If you're not affiliated with a facility, or you don't know its NPI number, you may leave this blank. Which specialties can you offer training in? If you offer telepsych, but require students to be physically present during telepsych sessions, please select In Person. If you allow students to connect to telepsych sessions remotely, select Remote Student. If you allow both In Person and Remote Student, please select both specialties. Acupuncturist & Herbalist Acute Care in an Urgent Care setting in an Inpatient setting Acute Care in an Urgent Care setting in an outpatient setting Addiction Medicine Adult Medicine Advanced Assessment Allergy Anesthesiology Anti Age, Medical Spa, Weight loss, Aesthetics Cardiology CNO, Chief Nursing Officer Dermatology Doctorate Thesis Advisor / Scholarly Advisor Education specialist based in a hospital Emergency Medicine / Adult or Pediatric / ER Endocrinology Endoscopy ENT Family medicine or Primary Care Gastroenterology Genetics Geriatric Medicine / Elder Care Gynecology (GYN) Gynecology specializing in Fertility and Reproductive medicine Gynecology with Obstetrics (OB/GYN) Hospice Hospital Based Care Hospitalist Indian Health Services Infectious Disease Intensivist Internal Medicine Leadership and Management C-suite level mentor Medical Assistant Office Based Medical Science Liaison Natural and Holistic Family Medicine Neonatal / Pediatric ICU Nephrology Neurology Nursing Hospital Based Nursing Informatics Nursing Office Based Obstetrics Occupational Medicine Oncology Ophthalmology Osteopathic Manipulative Medicine Pain Management Palliative care Pediatrics Physiatrist Psychiatry (in person, Discuss patient mix with student) Psychiatry (remote, discuss patient mix with student) Psychiatry - Child and Adolescent (in person) Psychiatry - Child and Adolescent (remote student) Psychiatry - Inpatient in a Hospital setting (ask specificaly what population is being served) Psychology / Psychotherapy (in person) Psychology / Psychotherapy (remote student) Psychology/ Psychotherapy - Child and Adolescent (in person) Psychology/ Psychotherapy - Child and Adolescent (remote student) Pulmonary Radiology Radiology Interventional Research Resident Resident NP or PA Rheumatology Sleep Medicine Sports Medicine Surgery Bariatric Surgery General Surgery Orthopedics Surgery Plastic Traditional Chinese Medicine Urology Wound Care Will you accept male students for Women's Health? Yes No EDUCATIONAL INFORMATION Curriculum Please selectNP StudentPA StudentMedical Student Please select the curriculum you're currently enrolled in and seeking placement for. School Select your curriculum first Please contact us if you don't see your school listed. -------------------------------------------------------------------------------- I accept the Terms of Service and Privacy Policy I agree to receive NON-marketing SMS messages at the mobile phone number entered above. We send SMS messages to update you on the status of your preceptor placement requests and notify you when preceptors send you offers. We do NOT send marketing messages and we will NEVER spam you. This is NOT required, but highly recommended, to ensure that you don't miss any offers or important updates. You can opt out at any time. Enroll me in a FREE NP Nation Lite membership (optional) NP Nation is a nationwide advocacy group and membership organization for nurse practitioners. NPN advocates for nurse practitioner rights and participated in campaigning for independent practice. As an NPN member, you'll gain access to discounted malpractice insurance and we'll send you occasional email offers for relevant products and services. There's NO COST for the Lite membership and you may opt-out at any time. SUBMIT × Loading... Skip to content Call us Toll Free: 800-701-5550 Login Sign Up Free * Find a Preceptor * Become a Preceptor * Clinical Site Partners * Residency Program * FAQs * Student FAQs * Preceptor FAQs Menu * Find a Preceptor * Become a Preceptor * Clinical Site Partners * Residency Program * FAQs * Student FAQs * Preceptor FAQs Twitter Youtube Linkedin Facebook HomeBecome a preceptor BECOME A PRECEPTOR GET PAID TO BE A PRECEPTOR FOR NURSE PRACTITIONER STUDENTS Precepting has been part of the nursing field since its inception. It’s a great way for students to learn from the experience of practicing nurse practitioners or medical doctors. Most students need a few days a week, for about ten weeks, and with Clinical Match Me, you can now get paid to be a preceptor. THE PROBLEM WITH PRECEPTING With more than 600 masters and doctorate level nursing programs, plus 200 online programs, precepting has become burdensome for both preceptors and students. Now, more than ever, there are more students, more paperwork and more headaches for everyone. Competition for clinical learning opportunities has become fierce. sign up free PRECEPTORS We know in a perfect world, you’d gladly donate your time to precept nurse practitioner students. Unfortunately, in the real world, your time is at a premium and you need to make a living. That’s why as a Clinical Match Me preceptor, you’ll earn a substantial honorarium for each student you train. We make it possible for you to get paid for sharing your knowledge and experience with nurse practitioner students. sign up free OUR INNOVATIVE SOLUTION We developed a proprietary technology solution that organizes and streamlines the process of matching students with preceptors. Instead of suffering lost productivity, fielding endless calls and emails from students, just login to our online portal to review students who meet your requirements. View each student’s details in a standardized format, then click the Offer button to offer a preceptorship to a student. We’ll pay you a $1,000 honorarium for each student who accepts your offer. sign up free GET PAID TO BE A PRECEPTOR We know in a perfect world, you’d gladly donate your time to precept nurse practitioner students. Nevertheless, in the real world, your time is at a premium and you need to make a living. That’s why with Clinical Match Me, you can now get paid to be a preceptor. We created a platform that pays you for sharing your knowledge and experience with nurse practitioner students. We invite you to join our network as we redefine the concept of nurse practitioner precepting. sign up free LEARN MORE Watch this video to learn how to become a Clinical Match Me preceptor and start earning $1,000 for each student you precept. sign up free WATCH THE STEPS Clinical Match Me is the original nurse practitioner preceptor finder service. Twitter Youtube Linkedin Facebook Copyright © 2021 - 2024 Clinical Match Me LLC • All rights reserved GLOBAL HQ 1666 Ponce de León San Juan, PR 00909 800-701-5550 SERVICES * Preceptor Finder * Get Paid to be A Preceptor LEGAL * Privacy Policy * Terms of Service Copyright © 2021 - 2024 Clinical Match Me LLC • All rights reserved Students Matched Today * We matched Jennifer L, RN from Loganville, GA with Hannah B, APRN for a Family medicine or Primary Care rotation, starting on January 8, 2025 * We matched Jasmine M, RN from Hattiesburg, MS with Kelly L, PA for a Family medicine or Primary Care rotation, starting on January 1, 2025 * We matched Aleah G, RN from Jersey City, NJ with David A, DO for a Gynecology (GYN) rotation, starting on November 20, 2024 * We matched Mohammed R, RN from Greendale, WI with Katrina M, APRN for a Pediatrics rotation, starting on September 3, 2024 * We matched Kelli B, RN from Mobile, Alabama, AL with Dhruva P, APRN for an Adult Medicine rotation, starting on February 24, 2025 * We matched Bukola S, RN from Danville, IN with Lashelle A, FNP for a Family medicine or Primary Care rotation, starting on January 6, 2025 * We matched Eric W, RN from Rochester, NY with Sonia R, PA for a Family medicine or Primary Care rotation, starting on January 27, 2025 * We matched Taquana M, PMHNP from Pinson, AL with Anna D, PMHNP for a Psychiatry (in person, Discuss patient mix with student) rotation, starting on November 25, 2024 * We matched Guadalupe Nguyen L, RN from Lake Elsinore, CA with Jessica G, FNP for a Family medicine or Primary Care rotation, starting on October 29, 2024 * We matched Victoria D, APRN from Ellicott City, MD with Jean F, PMHNP for a Psychiatry (remote, discuss patient mix with student) rotation, starting on August 28, 2024 * We matched Hannah G, RN from Minneapolis, MN with Tolulope O, APRN for a Psychiatry (in person, Discuss patient mix with student) rotation, starting on January 21, 2025 * We matched Natalie W, RN from North Royalton, OH with Nerisa B, PMHNP for a Psychiatry (remote, discuss patient mix with student) rotation, starting on January 13, 2025 * We matched Mercy M, FNP from Fishers, IN with Nerisa B, PMHNP for a Psychiatry (remote, discuss patient mix with student) rotation, starting on August 26, 2024 * We matched Efemena I, RN from Aurora, CO with Shantel G, PMHNP for a Psychiatry (in person, Discuss patient mix with student) rotation, starting on February 26, 2025 * We matched Nicole I, FNP from Hackensack, NJ with Jacinto F, APRN for a Family medicine or Primary Care rotation, starting on September 9, 2024 * We matched Arthur B, RN from Ossining, NY with Jacinto F, APRN for a Family medicine or Primary Care rotation, starting on November 4, 2024 Our time: 3:44am EDT 1. 1. Service & Date 2. 2. Select Time Slot 3. 3. Details/Payment 4. 4. Confirmation * Service Zoom Meeting AugustSeptemberOctoberNovemberDecember SunMonTueWedThuFriSat 28293031123456789101112131415161718192021222324252627282930311234567 Cancel Next Step Go Back Cancel Next Step Go Back Cancel Confirm Appointment Close This Window Notifications