Pediatrics 1 Site and Specialty Form

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Pediatric Divisions

Mailing Address: OHSU Dept. of Pediatrics
Mail Code: CDRCP
707 SW Gaines Street
Portland , OR 97239-2901
Phone: 503-494-3195
Fax: 503-494-4953

Physical Location:
Child Development and
Rehabilitation Center (CDRC)
Office 2114D
Campus Map

PRINTABLE VERSION

Dustin Haferbecker, fourth year medical student, on a pediatrics rotation.

Dept of Pediatrics

MSTC Pediatrics 1

Our goals are to educate medical students about the unique physiology, pathophysiology, social, and health care needs of children and their families. The Department of Pediatrics hopes this will be an enjoyable and educationally valuable experience for all students. We value your experiences and evaluation and feedback is used on an ongoing basis to improve our clerkships.

Site and Specialty Selection Form

Student Last Name:
Student First Name:
Student Email:
I am register for::
Hospital Preference:
Date of Birth:
	Required for All students (mm/dd/yyyy).
Middle Name:
	Required for all students
Social Security Number:
	This is necessary for computer access. Please provide it. This is a secure site.
1st Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
2nd Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
3rd Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
4th Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
5th Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
6th Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
7th Specialty Choice:
	DCH Specialty Preference-Required for ALL STUDENTS.
Note:
	Please enter any special concerns.
Other Names:
	Please Enter Any Name Issues

Last updated: June 5, 2007

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