Contact Information

First Name *

Last Name *

Email *

CHS Other

CHS Information

Email:

Phone:

Other Information

Email:

Phone:

Location/Unit:

Supervisor:

Fax

Occupation *

Administrator Allied Health Professional Dentist Medical Technologist/Clinical Laboratory Scientist Nurse Occupational Therapist Physical Therapist Physician Physician Assistant Pharmacist Student

Hospital Affiliation *

Anson Community Hospital Carolinas Medical Center Carolinas Medical Center-Mercy Carolinas Medical Center-Pineville Carolinas Medical Center-University Cleveland Regional Medical Center Gaston Memorial Hospital Kings Mountain Hospital Lincoln Medical Center Northeast Medical Center Stanly Memorial Hospital Presbyterian Hospital (Novant) Union Regional Medical Center Other

Other

Are you a Preceptor?

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If yes, please list students' home institutions