Third Street Family Health Services - Behavioral, Dental, Medical, OB/GYN, Podiatry, Pediatrics, Suboxone, 44906, 44875

We provide Behavioral Health, Dental, OB/GYN, Women's Care, Medical, Pediatrics, and Podiatry. We have ten locations and all can be found in Mansfield, Ontario, and Shelby, Ohio. Our main location is located at 600 West Third Street, Mansfield, OH 44906.

Clinical Preceptor Request Form

Hello and Thank You for considering Third Street Fmaily Health Services as your potential Medical Home for Clinical Experience. Please complete this form and upon receipt you will be contacted within 72 business hours.

Today's Date *
Today's Date
Name *
Name
Is this your legal name *
DOB *
DOB

Address

Phone *
Phone

Please Complete the Following School Information

School Phone Number *
School Phone Number

Atleast one course is required

(Please note at this time we do not have a Pediatric Preceptor)

By electronically signing and submitting this request form you agree that all information is correct and that you may be contacted by TSFHS.

Date *
Date
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Third Street Family Health Services is a FTCA Deemed facility

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