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Royal Palm Beach Medical Group – Royal Palm Beach & Fort Lauderdale Locations
Royal Palm Beach Medical Group – Royal Palm Beach & Fort Lauderdale Locations
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Step 1
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Student Information
Full Name
Email Address
Phone Number
Date of Birth
School / Program Information
University / Nursing School
Program Type:
FNP (Family Nurse Practitioner)
AGPCNP (Adult-Gerontology Primary Care)
DNP Program
MSN Program
Nurse Practitioner (NP)
Physician Assistant (PA)
Medical Doctor (MD/DO)
Expected Graduation Date
Clinical Course Name & Number (if applicable)
Clinical Coordinator or Faculty Contact
Name - Coordinator or Faculty
Email Address - Coordinator or Faculty
Phone Number - Coordinator or Faculty
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Step 2 Title
Requested Clinical Rotation Details
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Royal Palm Beach
Fort Lauderdale
Either Location
Preferred Start Date:
Preferred End Date
Total Clinical Hours Needed
Days/Times Available
Type of Rotation Needed:
Primary Care
Adult Primary Care
Family Medicine
Internal Medicine
Other (explain)
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Proof of enrollment in an accredited NP program
Clinical affiliation agreement (if required by school)
Liability/malpractice insurance (student coverage)
Background check
Drug screening (if applicable)
Immunization records (MMR, Hep B, Varicella, Tdap)
TB test or QuantiFERON
COVID-19 vaccination record (or exemption documentation)
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Step 3 Title
Experience and Goals
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None
Some clinical hours completed
Prior healthcare experience (Describe)
Skills or procedures you would like to strengthen:
Career goals after graduation:
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Additional Comments or Questions
Student Signature
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Signature
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Date
(CID : 24781)
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