Request Information About a Preceptorship

If you're interested in the possibility of being a preceptor and would like more information, please tell us a little bit about yourself on the form below and someone will contact you, usually within 2 business days

Name:*

Email:*

Phone number:*

Practice site (please include full street and mailing addresses):*

Number of years practicing:*

Number of years precepting:*

Preceptor license number:*

Description of pharmacy site:

Description of activities at your pharmacy site:

Which type of experience interested in precepting:
Introductory Experience
Community
Health System
Other

Advanced Experience
701—Advanced Community Pharmacy
702—Institutional Pharmacy
703—Ambulatory Care Pharmacy
704—Adult Internal Medicine
705—Patient Care Elective
706 or 707—Non-Patient/Patient Care Elective

What is your precepting philosophy?

Does your site currently have a rotation coordinator? If yes, please list their name

 

* = Required