Please fill out the following form with as much information as you can to help us provide effective advising for you.

* indicates a required field

Name*:

Preferred Name:

Preferred Pronouns:

UW Email Address*:

Phone Number*:

Entered Year*:

Anticipated Graduation Year*:

Expanded*:
YesNo

Dual Applying:
YesNoUnsure

College Mentor*:

If you've met with a Family Medicine Advisor previously please list their name*:

Please list your availability (days/times) during business hours that you're able to meet with an advisor.
The more options you give us the easier it is to schedule you*:

Are you in Seattle for an in-person meeting or do you need/want a remote meeting?*:

What do you want to talk about?*

BACKGROUND INFORMATION:

Where did you do your FM Clerkship?*:

FM Exposure & Related Activities So Far*:

Career Interests*:

Research:

Other Specialties of Interest:

GRADES

Required Clerkships

Family Medicine Grade:

Internal Medicine Grade:

Psychiatry Grade:

Pediatrics Grade:

Surgery Grade:

OB/GYN Grade:

Any Failing Grades (including preclinical)?
YesNo

Do you have any concerns that could affect your application?

BOARD SCORES

Step 1:

Step 2 CK:

Step 2 CS:

PLANS: Advanced Clerkships/Sub-I(s): 

RESIDENCY: Characteristics of your ideal residency training program (eg, location, rural vs urban, etc):

LOR: Name/Specialty of Letter Writers (if known):