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NOTE: This form is being provided as a convenient method for our students and/or community-based physicians to reach the Predoctoral division of the Department of Family and Community Medicine. Please do not use this form for patient appointments and/or doctor/patient communications.
If you are either a student or family physician and you would like to contact us, please complete following.
Physician click here to start. Student click here to start. ______________________________________________________
Physician Section
Who are you?* required. Current Physician (taking UKCOM students) New Physician (wanting to take UKCOM students) Areas of Interest Interested in precepting students - please contact me with details on opportunities. I am most interested in: 1 week externship (usually in November) 4 week/3rd year clerkship (July-July) 4 week/4th year clerkship (July-May) Interested in teaching students (lectures tied to established medical courses or to teach a new concept/course) Please contact me with details on opportunities Please provide additional comments or clarifications related to your interests in the space below: Contact Information Name* (required) Mailing Address: Mailing Address (cont.) City State/Province Country Zip Code / Postal Code Phone Number E-mail* (required) If you want to be contacted by office: yes Contact preference: phone email phone or email: CURRENT PHYSICIANS: If you have had students from UK in the past and want copies of your feedback reports, please indicate the years: Feedback Reports* *(Indicate years) NEW PHYSICIANS OR RENEWALS: If you are a new physician interested in being appointed to our department, please check: Appointment Complete the attached preliminary application form (opens in new window) and submit a copy of your CV via email to Shari Levy - predocfp@email.uky.edu If you are a current physician needing assistance related to your re-appointment process, please check: Re-appointment**
required.
Current Physician (taking UKCOM students)
New Physician (wanting to take UKCOM students)
Areas of Interest
Contact Information
CURRENT PHYSICIANS: If you have had students from UK in the past and want copies of your feedback reports, please indicate the years:
NEW PHYSICIANS OR RENEWALS: If you are a new physician interested in being appointed to our department, please check:
Complete the attached preliminary application form (opens in new window) and submit a copy of your CV via email to Shari Levy - predocfp@email.uky.edu
**Please provide any comments relating to reappointment or appointment:
_______________________________________________
Student Section
Name* (required) Mailing Address: Mailing Address (cont.) City State/Province Country Zip Code / Postal Code Phone Number E-mail*(required) Who are you?* required. Current Student Future Student
Please check each box on which topic that you would like to receive information.
Want to come as a Visiting Student International Rotation* *Comment on Region of Choice Rural Training Track opportunities Want an Advisor Interested in Research* *Comment on Research
Please provide additional comments or any clarifications
related to your interests in the space below:
