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Block Elective Request Form
Please use this to select your preferred elective experience during your upcoming elective block.
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Name
*
Your answer
Which block are you planning your elective for?
*
Block 1
Block 2
Block 3
Block 4
Block 5
Block 6
Block 7
Block 8
Block 9
Block 10
Block 11
Block 12
Block 13
Which elective are you requesting?
*
Choose
Administration in Medicine
Breast Feeding Elective
EKG Elective
Emergency Medicine
Endocrinology
Hematology/Oncology
Hospice and Palliative Care
Infectious Disease
Integrative Medicine
Medical Spanish
Nephrology
Nutrition - please complete alternate form
OB rotation at TCH (for away rotation, see GH elective form)
Patient Safety Systems
People with Disablities
Primary Care Psychiatry
Pulmonary
Radiology
Rheumatology
Spirituality in Practice
Sports Medicine
Urgent Care Elective
Women's Health - please complete alternate form
Wound Care
Is there a specific location you hope to rotate at? If so, please describe.
Your answer
Anything else you want Judy to know?
Your answer
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