School Affiliation

Program/Placement Coordinator & Contact Info

Preceptor Credentials

Preferred Provider (Optional)

Preferred Location (Optional)

Hours Needed

  • 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.