Resident Profile Form

Name (first, M.I., last, maiden):

Residency program:

Date of Completion:

Program level:

Present address (number & street, city, state, zip):

Telephone (office):

Telephone (home):

License number:

Date issued:

Date expires:

Malpractice Insurance carrier :

Effective Date:

Experation Date:

Time periods available for Locum Tenens:

Time periods not available for Locum Tenens:

List procedures performed:

List practice limitations:

Comments:

Preferred e-mail address:
(please be specific, i.e: tsmith@kumc.edu)

How did you hear about Kansas Locum Tenens? Please be specific.

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