PLACEMENT REQUISITION FORM

CHECK ONE OF THE FOLLOWING:

 Externship
 Employment

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Doctor/Facility:

Street Address: 

Suite/Floor:  

City: 

State:  

Zip Code: 

Telephone:  

Fax  Number:  

E-Mail Address: 


Type of Practice: 

Days of Operation:  

Hours of Operation: 

Contact Name: 



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REQUIRED SKILLS

FRONT OFFICE:

Telephone Appt. Scheduling Typing Charting Billing/Collections Medical Transcription Bookkeeping/Pegboard Insurance Filing Computer

BACK OFFICE:

Injections CPR Assisting Blood/Collection BP/Vital Sign Tray Set-up Sterilization

LABORATORY:

CBC Hct/Hgb X-Ray UA EKG X-Ray Processing Cultures Other

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Special Requirements/Qualifications: