OMFS - Candidate Questionnaire

CANDIDATE QUESTIONNAIRE REGISTRY

Personal Information

First name:		DDS MD
Last Name:
Mailing Address:
City:		State: Zip:
Home Phone:		Cell Phone:
Pager:		Preferred Contact# Home Cell Pager
Email Address:		Best time to reach you:

Tell Us About Yourself

Marital status:	Married Single Engaged Divorced
Spouse's name:		Spouse's occupation:
Children/ Ages:
Your home town:		Birth date:
US Citizen:	Y es No	*If no, Visa status:
Tell us a little bit about your family:
Hobbies or special interest:
Any special needs for your family we should be aware of:
Other information you would like to share:

Professional Information

Certification:	Board eligible Board certified		Year certified or expect to be:
If board eligible, when (if) will you be taking your boards:
College/undergrad:		Graduated:
Medical School:		Completed:
Internship:		Completed:
Residency:		Completed:
Fellowship location and specialty of training:
Licensure in what state(s):
Other information you would like to share:

Malpractice History

Have you ever been named in a malpractice suit?	Yes* No
Have you ever had a license suspended or revoked or limited?	Yes* No
Have you ever had your hospital privileges suspended or revoked?	Yes* No
Have you ever been treated for drugs or alcohol abuse?	Yes* No
Have you ever been convicted of a felony?	Yes* No
* If yes to above questions, please explain and attach any documents if needed:
Other information you would like to share:

General Questions

Where do you want to practice (please be very specific)
1st Choice:
2nd Choice:
3rd Choice:
4th Choice:
What year did you finish or will finish Residency/Fellowship:
How much longer do you want to practice:
Would you prefer a practice in a rural or metro area (if rural how far to metro)
What opportunities have you already contacted (be specific so we do not contact them):
Practice philosophy:
Preferred office hours:
Preferred call schedule:
If you are leaving a practice, please explain departure reasons:
Is a computerized office important to you. Yes No
What are your thoughts on digital radiography:
What are your thoughts for having a registered nurse for recovery:
Will you see Medicaid patients? Yes No
How do you feel about financial arrangements for patients that cannot pay:
Describe your personality in the office environment:
Other information you would like to share:

Preferred OMS Situation

Associate/Partnership Employee/Hospital Practice Transition 1-5 yr Buy Out Buy a Practice

Acceptable years to partnership:

Describe your ideal working environment (staff, number of partners, number of offices, etc.):

When would you like to start:

Briefly explain your preferred contract details:

What are your minimum salary requirements:

Do you have any outstanding loans and if so what is the amount:

Other information you would like to share:

Attach CV: