Clinical Student Rotation Registration
Please fill out the form below to register as a clinical student with Gaston Family Health Services.
Required = *
District Of Columbia
Emergency Contact Info*
A.T. Still University
Davidson Community College
East Carolina University
East Tennessee State University
Edward Via College of Osteopathic Medicine
Frontier Nursing University
George Washington University
Lenoir Rhyne University
Medical Centers Institute
NC A&T State University
St. Joseph's College
UNC Chapel Hill School of SW
UNC Greensboro School of Nursing
UNC School of Dentistry
United States University
University of South Alabama
University of South Carolina
University of Southern Indiana
Wake Forest University
Western Piedmont Community College
Winston Salem State University
Program/Placement Coordinator & Contact Info*
Clinical Rotation Specialty Needed*
Student Degree Program*
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
Terms & Conditions*
I authorize all 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 Services as well as those supplying said information, from any and all liability from these investigations.
I understand that Gaston Family Health Services holds every employee, volunteer and student accountable under HIPPA. Sharing information regarding patients, employees, or the clinic 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 clinical student rotation program. I will provide a recent (within 1 year) PPD (Tuberculosis Skin 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 on this application to 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
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It means a lot to us, just like you do!