Please list three professional references that are able to provide detailed information about your professional skills, capabilities, and character, and who have had clinical contact with you in the past two years. Please let them know we will be contacting them.
I confirm that all information submitted by me in this application, including the information in the attestation section, is true and correct to the best of my knowledge, and I agree to provide all further information that may be necessary for Doctors Making Housecalls, LLC, its agents, or employees to evaluate my professional competence, character or ethics. I also confirm that in making this application, I am familiar with the principles and standards that apply to and govern my profession and specialty. I understand that any false or misleading information given in my application or interview(s) may be considered as cause for termination of employment.
I hereby authorize Doctors Making Housecalls, LLC, its agents, or employees, to consult with any individual or organization with whom I have been associated, who may have information bearing on my professional competence, character, or ethics, and to inspect any material, including my credit and criminal history, and my own medical records, relevant to this application. I hereby consent to the release of such information and material, and release from liability individuals and organizations that provide such information or material in good faith to Doctors Making Housecalls, LLC, its agents, or employees.
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