Recently an individual expressed an interest in working as a locum tenens physician with our company and listed you as a reference. Please take a moment to complete this form. This is a professional reference request, so please answer the questions to the best of your knowledge. Please initial below to indicate you have read this and understand the purpose of this form. Thank you in advance for your assistance.
What is your practicing specialty?
If you answered Poor or Unsatisfactory for the previous question, please take a moment to explain in the space provided below.
If you answered Poor or Unsatisfactory for the previous question, please take a moment to explain in the space provided below.
If you answered Poor or Unsatisfactory for the previous question, please take a moment to explain in the space provided below.
If you answered Yes or Sometimes for the previous question, please take a moment to explain in the space provided below
If you answered "Poor" or "Unsatisfactory" for any question(s), please use the space below to explain.
