Physician Registration Form



Physician First Name*:		Last Name*:
Address*:
City*:		State*:	ZIP*:
Phone*: (xxx-xxx-xxxx)		Fax:	Best time to call*:
Email*:		Locum Tenens:	Permanent Placement:
Date Available:


Specialty
	Adult/General Child/ADO	Adolescent Geriatrics	Forensics Other
Board Certified:	YesNo
States where I am licensed:
ALAKAZARCACOCTDEFLGAHIIDIL INIAKSKYLAMEMDMAMIMNMSMOMT NENVNHNJNMNYNCNDOHOKORPARI SCSDTNTXUTVTVAWADCWVWIWY


Practice Situations
	In PatientPsych ERConsults Out PatientMed DirDischarge PrisonsPhysicalsIntake Night CallHistoriesPsychotherapy Weekend CallPsychopharmacology

States I am interested in working
ALAKAZARCACOCTDEFLGAHIIDIL INIAKSKYLAMEMDMAMIMNMSMOMT NENVNHNJNMNYNCNDOHOKORPARI SCSDTNTXUTVTVAWADCWVWIWY
DEA Certificate	YesNo
US Citizen	YesNo

D & Y locums tenens permanent placement