Payment Confirmation

Are you registering as a student, a preceptor/attending, or a Medical Practice?

Student

Preceptor or Attending

Medical Practice

Name

First

Last

Company

Office Phone

Extension

Email address

Mobile Phone

City

State

Password

Password Confirmation

Gender

Male

Female

Professional Information

NPI No

If you have an NPI number, enter it here. If not, leave this blank.

Degree

Please select your CURRENT health care degree. For example, if you are in school to become an APRN, your CURRENT degree is probably RN.

Facility NPI No

If you're affiliated with a medical practice, clinic or hospital, please enter the facility's NPI number. This is different from your personal NPI number. If you're not affiliated with a facility, or you don't know its NPI number, you may leave this blank.

Will you accept male students for Women's Health?

Yes

No

Educational Information

Curriculum

Please select the curriculum you're currently enrolled in and seeking placement for.

School

Please contact us if you don't see your school listed.

I accept the Terms of Service and Privacy Policy

I agree to receive NON-marketing SMS messages at the mobile phone number entered above.

We send SMS messages to update you on the status of your preceptor placement requests and notify you when preceptors send you offers. We do NOT send marketing messages and we will NEVER spam you. This is NOT required, but highly recommended, to ensure that you don't miss any clinical placement offers from preceptors or important updates. You can opt out at any time.

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Professional Information

Educational Information

Payment Confirmation