TEXAS DOCTORS GROUP
A Physician Search/Placement Service
P.O. Box 177, Austin, TX 78767
Telephone: (512) 476-7129
www.texasdoctorsgroup.com
Completion of this form and your signature below indicate that you wish The Texas Doctors Group (TDG) to search for positions on your behalf, that the information you provide herein is true and correct, and that you will keep confidential information provided to you by TDG
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1. Medical Specialty or field you wish to practice
Family Practitioner
Pediatrician
General Surgeon
Internist
OB/GYN
Rheumatologist
Cardiologist
Psychiatrist
Other
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2. When do you wish to start a new position?
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Last Name
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First Name
Middle Name
(if any)
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Permanent or Home Address - Street Name
Address Line 2
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City
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State/Province/Region
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Zip/Postal Code
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Home Phone Number
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Office Phone Number:
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Country
Address for correspondence
Same as Permanent or Home Address
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Email Address
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Confirm Email Address
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3. Date of Birth
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4. Height
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5. Weight
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6. Place of Birth – City, State, Country
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7. If you are not currently eligible for reciprocity licensing, when and where do you plan to take the FLEX exam?
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8. Have you passed FLEX?
Yes
No
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9. FLEX score?
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10. Are you willing to take another state board examination of necessary?
Yes
No
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11. Please list those branches of medicine in which you are specialized
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12. Indicate those branches of medicine in which you are particularly interested in practicing
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13. What preference do you have as to geographic location?
North Texas
South Texas
Coastal Texas
West Texas
East Texas
Rio Grande Valley of Texas
Other States (list)
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14. Will you consider other locations?
Yes
No
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15. Would you consider an appointment requiring an investment?
Yes
No
16. What is the maximum amount you would probably invest?
17. Do you require a salary or guarantee? How much?
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18. Is this figure negotiable?
Yes
No
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19. Type of practice preferred:
Solo
Associate
Group
Institutional
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20. Size of city you would like to practice in:
Small
Medium
Large (over 100,000)
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21.What languages do you speak fluently?
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22. Are you married? If so, give name of spouse.
No
Yes
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23. Do you have any children? What are their ages?
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24. What is your military status in the USA?
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25. In country of citizenship?
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26. Please give the names, title, official positions, telephone numbers and complete addresses of three or more physicians personally acquainted with you and your abilities as a physician, and who could be contacted at a later date for references. References will be contacted only after you have received an offer.
1. 2. 3.
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27. From what school did you graduate?
List
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Name of School, Address of School (city, state, country), Degree received, Year graduated:
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28.
Where did you serve your internship?
List
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Name of Hospital, Address of Hospital (city, state, country), Dates (From - To)
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29.
What residencies, if any, have you served?
List
:
Name of Hospital, Address of Hospital (city, state, country), Dates (From-To), Field of Medicine, Reference and Telephone No.
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