Provider's Full Legal Name

Medical Degree

Medical Specialty

Board Certified

Phone Number

Your email

Home Address

Available to Start

Locum or Perm

Shifts available or ideal schedule

Interview Availability

Years of Experience

Provider Selling Points

State License/Number

Expiration Date

NPI#

DEA active and unrestricted

Active Certifications (BLS? ACLS?)

Experience and or procedures relevant to opening

Schedule Restrictions

Pay Rate

(Internal Staff for Medmal) Bill Rate

Do you require a hotel
YesNo

Do you require a flight
YesNo

Do you require a rental car, or mileage
YesNo

Malpractice History: (list dates, payout and brief explanation)

Have you been convicted or charged with a crime other than a traffic violation

Has your professional license or certification been investigated or suspended

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