Lincoln Memorial University-
DeBusk College of Osteopathic Medicine

Interest Form

Craig Lenz, D.O.
Senior Associate Academic Dean/Associate Dean for Clinical Sciences
6965 Cumberland Gap Parkway, Harrogate, TN, 37752
Phone: 423-869-7123           Fax: 423-869-7078           julie.iliff@lmunet.edu

David Metcalf, PA-C, MPAS
Director of Clinical Education, LMU-DCOM PA Program
Phone: 423-869-7755        Fax: 423-869-6672         david.metcalf@lmunet.edu

Name

Address

City    State       Zip

Phone

Fax

List of Specialties

AOA#

Hospital Privileges(City and State)

Is your practice rural or urban? Rural Urban

Areas of Interest

Hospital Supervision
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Office Preceptorship
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Lectures
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No
If you answered yes above, please indicate topics below

Facilitate and Teach on Campus
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Full Time or Part Time Campus Faculty
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Participate in Student Interview Process
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Participate in Student Shadowing and D.O. Letter of Recommendation to LMU-DCOM
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No