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Professional Reference Form
About your facility
Is the facility a hospital?
Type of clinic
Hours of operation
Average number of patients per day
Percentage of patients that are children
Please enter a number from
Number of nurses at facility
Number of PA's at facility
Does the position you want to fill require any of these
Regular week day schedule
Information about the position
Indicate if you need any of these specialties
Internal medicine for pediatrics
Please specify other specialty needed
When do you need to fill this position by?
MM slash DD slash YYYY
Indicate certification requirement
Board certified only
Board eligible or certified
No certification needed
Indicate which of these are needed
MD (medical doctor)
DO (doctor of osteopath)
Foreign but trained in America
Foreign language necessary
ABAT (American born and American trained)
Physician candidate preferences
Knowing everything is negotiable based on experience and credentials please give ranges for the following.
Please be as explicit and definitive as possible. This will enable us to market more effectively and receive only serious inquiries.
Base salary range
Sign on bonus range
Production bonus range
Relocation allowance range
CME allowance range
Insurance benefits (list type)
Retirement plan (profit sharing, 401k)
Partnership availability (length of time before eligible)
Paid vacation time off (number of weeks)
Is there a Provider ID you wish to include with your inquiry?
The Provider ID can be found next to "Inquire Now" at the bottom of the candidate post
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