logo
Menu
Become a Volunteer Graphical header

 

Physician Shadowing Application

This application is a request by the person named below (“Applicant”) to participate in the Pikeville Medical Center Physician Shadowing Program (“Program”).  Submission of this application does not guarantee that applicant will be selected to participate in the Program.

First Name:
Middle Name:
Last Name:
Are you 16 or older? Yes No
Date of Birth:
Home #:
Cell #:
Email Address:
Present Address:
SSN:
Timeframe of shadowing request:
Emergency Contact:
Name:
Phone #:
I represent and warrant that I am not now nor have I ever been (i) listed by an agency or entity as excluded, debarred, suspended, or otherwise ineligible to participate in any federal, state, or private health care benefit program; (ii) listed as an excluded party by the U.S. Department of Health and Human Services or General Services Administration; (ii) been charged with, convicted of, pled guilty to, or entered a plea of non contendere (or any similar plea) with respect to any healthcare related offense; or (iv) been sanctioned for any form of healthcare fraud or abuse. I will notify Pikeville Medical Center immediately upon the commencement of any proceeding against me in which the outcome may be any of the above-described events.

I further agree to execute any documentation necessary to comply with PMC’s vaccination policy, including any authorizations to release my protected health information or otherwise apply for an appropriate exemption. I agree that before I can be accepted as a physician shadow I must comply with PMC’s vaccination policy and failure to comply may lead to me not being accepted as a physician shadow or being dismissed as a physician shadow.


I hereby attest that all of the foregoing information is true and correct. I authorize Pikeville Medical Center to obtain such background and personal reports as are deemed necessary to verify that the information I have supplied is true and accurate. A copy of this authorization is valid as the original.
Participant Signature:
Date:
If younger than 18 years of age, please have a Parent/Legal Guardian read and sign the following:



I hereby attest that I am the Parent/Legal Guardian of the Applicant and that all of the foregoing information is true and correct. I authorize Pikeville Medical Center to obtain such background and personal reports regarding the Applicant as are deemed necessary to verify that the information I have supplied is true and accurate. A copy of this authorization is valid as the original.
Parent/Legal Guardian Signature:
Date:

 

>>><<<

Latest News and Events

    • OCTOBER 24, 2023
    October Is Also a Time for Liver Cancer Awareness

    October Is Also a Time for Liver Cancer Awareness

    While most people are aware that October is a time to bring awareness to breast cancer, many do not realize it is also a time set aside to learn more about liver cancer and honor those who have been affected by it. Liver cancer appears in patients as either primary, meaning cancer originates in the

    Read more
    • OCTOBER 9, 2023
    Lawson Cancer Center Celebrates Grand Opening of Long-Awaited Expansion Project

    Lawson Cancer Center Celebrates Grand Opening of Long-Awaited Expansion Project

    On Monday, September 25th, the first patients were welcomed into the brand-new expanded space at the Lawson Cancer Center (LCC) on the 11th floor of the Pikeville Medical Center Clinic Building. On its first day open, 15 patients received specialized care in the 24 additional treatment rooms created by a nearly $5 million grant from

    Read more
    • SEPTEMBER 4, 2023
    Lawson Cancer Center Providing Comprehensive Oncology Care

    Lawson Cancer Center Providing Comprehensive Oncology Care

    The Lawson Cancer Center (LCC) at Pikeville Medical Center (PMC) provides healing and comfort for individuals and families navigating the challenging journey of a cancer diagnosis and treatment. Patients at the LCC receive comprehensive care, personalized treatment and unwavering support from the entire oncology team, which embraces a multidisciplinary approach to cancer care. This group

    Read more
    • MARCH 24, 2023
    PMC Now Offering Pet Scans to Target Prostate Cancer

    PMC Now Offering Pet Scans to Target Prostate Cancer

    On March 10, 2023, the Pikeville Medical Center (PMC) Diagnostic Center team reached another milestone by performing the region’s first PET scan designed specifically to detect prostate cancer. PMC can now perform a specialized scan that detects cells indicating prostate cancer. The risk of developing prostate cancer increases as men age. Second to skin cancer,

    Read more
© 2013-2022 Pikeville Medical Center, all rights reserved.
Pikeville Medical Center