Emergency Contact Info
District Of Columbia
Program/Placement Coordinator & Contact Info
Preferred Provider (Optional)
Preferred Location (Optional)
Bessemer City Health Care Center
Catawba Family Care
Davidson Medical Ministries - Lexington
Davidson Medical Ministries - Thomasville
Gaston Complete Health
Gaston Family Health Services
Gaston Family Health Services, Inc.
Gaston Family Medical Center
GF Counseling Center
GFHS Adult & Pediatric Medicine
GFHS Cherryville - Adult and Pediatric Medicine
GFHS School Health A Ashley Welllness Ctr
GFHS School Health A Mineral Springs
GFHS School Health A Mobile Medical Unit
GFHS School Health Alliance SBSW Pgm
GFHS School Health Alliance WSPA MHCC
GFHS School Health Alliance WSPA Wellness
GFHS Teen Wellness
HEALTHNET IREDELL MAP PROGRM
Helping Hands Health Center
Highland Health Center
Statesville Children's Clinic
Statesville Family Medicine
I authorize for all named references and educational institutions to release personal and professional information to Gaston Family Health Services. I also consent to a criminal background search, if required. I further release Gaston family Health Centers as well as those supplying said information, from any and all liability from these investigations.
I understand and agree that at no time will any information obtained as a result of my assignment at Gaston Family Health Services with regard to patients, employees or the clinic as a whole to be revealed to anyone other than those authorized to receive it. I understand that the giving of such information to those not authorized to receive it is unlawful and shall be sufficient cause for my immediate dismissal.
I authorize Gaston family Health Services to complete a required health review to enter the preceptorship program. I will provide a recent (within 1 year) ppd (tuberculosis skin test test) result. I understand that any positive reaction to the PPD test may also be followed up with further testing.
I understand that any false statements made as part of my application to with Gaston Family Health Services may be considered sufficient cause for dismissal.
I will provide GFHS with sufficient notice regarding changes/absences from planned and scheduled work commitments.
I agree to undertake (or provide evidence of within the last year) OSHA/HIPAA training, and job related training as necessary and as specified by Gaston Family Health Services, at no cost to me.
Agree with the terms and conditions