Family Medicine Year 4 Electives Request Form
Family Medicine Year 4 Electives Request Form
Fields denoted by an asterisk (
*
) are required.
Name
Name
*
First
Last
Email Address
*
Campus
Campus
London
Windsor
Do you have a confirmed family medicine elective?
Do you have a confirmed family medicine elective?
Yes
No
In which block(s) (select all that apply)
In which block(s) (select all that apply)
1
2
3
4
5
6
7
8
Please list your desired locations and/or preceptors below:
Please include comments about how many family medicine electives you would like and in which specific blocks. I will do my best to accommodate: