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Request for Preceptor

With our vision on education and community service, our goal at Trinity Mother Frances Hospitals and Clinics continues to be assisting with the education process of future health care professionals. With a formal process in place, once we receive your request, we will determine if it meets the basic criteria for further consideration for a clinical rotation within Trinity Mother Frances. We appreciate the opportunity to serve you, our customers, with your educational needs. Thank you for your interest in pursuing a clinical rotation with our facility.

* Indicates required information
I am seeking an educational opportunity in the following area 

First Name * 
Last Name * 
Today's Date *  (mm/dd/yyyy)
Student Program Discipline 

If Other, please specify:

Licensed Independent Practitioner Request (No School Affiliation. State Reason for request here and complete remainder of application) 
Are you employed with TMF? * 
Email Address * 
Mailing Address * 
City * 
State * 
Zip * 
Phone Number * 
What encouraged you to select TMF? * 
Institution Name (College, University or School) * 
Institution's Address * 
Institution Contact Person's Name * 
Institution Contact's Email * 
Institution Contact's Phone Number * 
Course Title Requiring Clinical Hours * 
Semester and Year Applying For (only one at a time) * 
Date desired to begin clinical *  (mm/dd/yyyy)
Number of hours required * 
Approximate end date of clinical *  (mm/dd/yyyy)
Please list your top 2 objectives for seeking this clinical rotation: * 
1st Preceptor Name * 
1st Preceptor Title * 
1st Preceptor Clinic or Hospital Department * 
1st Preceptor Email * 
1st Preceptor Phone Number * 
2nd Preceptor Name 
2nd Preceptor Title 
2nd Preceptor Clinic or Hospital Department 
2nd Preceptor Email 
2nd Preceptor Phone Number 
3rd Preceptor Name 
3rd Preceptor Title 
3rd Preceptor Clinic or Hospital Department 
3rd Preceptor Email 
3rd Preceptor Phone Number 
Initial the box to certify that you have read and accept the requirements * 

As the student, I acknowledge I have satisfied the required immunizations, drug screen and criminal background check and my Institution has on record:

Immunizations: Hepatitis B, MMR, Varicella, Pertussis, TB Skin Test (or Chest X-Ray) Flu. One of the following: 1) Verification of immunization, 2) Request for Religious Exemption from Influenza Vaccination, or 3) Request for Medical Exemption from Influenza Vaccination.Drug ScreenCriminal Background Check

Additionally, I recognize while I am conducting my clinical rotation that I will be required to:

Wear my University Student Name Badge in full view identifying me as a studentIf you do not have a current University Student Name Badge you must be sure to have one made through your University before starting your clinical rotation.

Wear any uniform approved by my university or contact my preceptor to determine what is acceptable in the clinical rotation practice. (Uniform scrubs or business attire only. Absolutely no jeans are allowed.)

Trinity Clinic

Trinity Clinic is the area's preferred multispecialty medical group, with over 350 physicians and mid-level providers representing 40 specialties in 36 clinic locations serving East Texas.

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