Letter of Intent

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Letter of Intent

I am interested in partnering with Eastern Michigan University’s Physician Assistant Program to provide PA students opportunities to obtain clinical practice experience by serving as a clinical preceptor. I realize that this is a preliminary request to identify potential sites for clinical practice experiences. I understand the program will contact me with more information.

Preceptor Full Name: *

Preceptor Credentials: *

PA-C

Other:

Preceptor Email Address: *

Preceptor Phone Number:

If Applicable, Name of Supervising Physician:

Name of Practice: *

Practice Setting/Specialty: *

Emergency Medicine

Family Medicine

General Surgery

Internal Medicine

Pediatric Medicine

Psychiatric Medicine

Women's Health

Other:

Required

Practice Setting(s): *

Outpatient

Inpatient

Emergency Deptartment

Operating Room

Telemedicine

Other:

Required

Patient Demographics: *

Infant (<= 2 years)

Child (3-11 years)

Adolescent (12-18 years)

Adult (19-64 years)

Elderly (>=65 years)

Behavioral & Mental Health

Women's Health

Required

Practice Mailing Address: *

If Applicable, List Other Facilities Where Students may Go:

Have you Ever Taught Students in the Clinical Setting? *

Yes

For non-PA provider, Have you Previously Worked with a PA?

Yes

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