New Preceptor Recommendation Form

Please fill out the following form if you wish to recommend a NEW preceptor for the GIMSPP program.  As the program grows, we will need more and more physicians from both urban and rural/underserved areas to precept our students.

Remember the requirements of a GIMSPP preceptor:

  • Board certified in Internal Medicine
  • Possess a current Texas medical license with no restrictions from the Texas State Board of Medical Examiners
  • Practice at least 40-50% general internal medicine apart from any other sub-specialties

Thank you for your recommendation!

Your Information

Your First Name *
Your Last Name *
Your Email (contact purposes) *
Are you a physician or a student? *

Recommended Physician's Information

Physician's First Name *
Physician's Last Name *
Physician's Company/Institution *
Physician's Address 1 *
Physician's Address 2 *
Physician's City *
Physician's State *
Physician's Zip *
Physician's Phone *
Physician's Email *
Have you already communicated with this physician about the GIMSPP program? *
(Maximum characters: 2000)
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