MMPT Clinical Shadowing Request Form

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Hello! Please fill out our short interest form so we can get to know a little more about you and why you'd like to observe at Mims Method PT.

Name (first and last): *

Email: *

Phone number: *

Why do you want to shadow/observe at Mims Method PT? *

What population are you most interested in seeing? *

Are you currently in school? If so, where and what year? *

What are you looking forward to most in a career in physical therapy? *

What do you look for in a team? *

What sets you apart from other applicants to shadow? *

Please list your preferred dates/times to observe. *

Would you be willing to provide feedback on your experience at Mims Method PT, including your observations of the clinic and the therapist you shadowed, if chosen for the shadowing opportunity?
*

Yes

I understand that it is not guaranteed that I will see patients, as each patient has the right to refuse a student in the room. Due to a recent influx of requests to shadow, MMPT is allowing one day of observation per student with exceptions on a case-by-case basis. *

Yes, I understand.

Would you be interested in future volunteer or employment opportunities? *

Yes

Other:

Anything else you'd like to share:

All patient information is subject to protection under the Federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191 ("HIPAA"), the Health Information Technology for Economic and Clinical Health Act, Title XIII of the American Recovery and Reinvestment Act of 2009 (the "HITECH Act"), and related regulations promulgated by the Secretary ("HIPAA Regulations ").

Due to the highly sensitive nature of our patient care, by signing below, you agree to follow all laws, rules, and regulations set forth by HIPAA. By signing below, you understand that HIPAA violations have both civil and criminal penalties.

Simply stated, by signing below, you agree to not share any information about which patients you see enter or exit the clinic, any information about patient's injury, level of function, etc. You agree not to share anything you read on our EMR or any other documents within the clinic. Any photography taken inside the premises may not identify any patient.

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