University of Kansas Medical Center
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Community Engagement >
Rural Health >
Kansas Locum Tenens >
Resident Profile Form
Name (first, M.I., last, maiden):
Date of Completion:
Present address (number & street, city, state, zip):
Kansas License number:
Malpractice Insurance carrier :
DEA Certificate Number:
DEA Expiration Date:
Time periods available for Locum Tenens:
Time periods not available for Locum Tenens:
List procedures performed:
List practice limitations:
Preferred e-mail address: (please be specific, i.e: email@example.com)
How did you hear about Kansas Locum Tenens? Please be specific.
To submit, please press
To clear the form and start over, please press
Do you have any questions?
Check out our KLT FAQs.
For more information about how to "Become a Provider" or "Request Service" contact Andrea Ellis at 913-588-1228 or firstname.lastname@example.org.