Standardized Patient Application

** (none of this information is shared with anyone outside this program) **

Preferred Campus:

Preferred Campus: CHS (Tulsa) Cherokee Nation (Tahlequah)
Name: Name: First Middle Last
Date of Birth: Date of Birth: / MM / DD YYYY
Availability: (are there any days of the week that you are routinely NOT available?)
Gender/Preferred Pronoouns:
Visible Scars: (surgical and otherwise)
Any visible signs of an ailment or previous injury such as swollen feet/ankles:
Any limitations to your mobility:
Height:
Weight:
Ethnicity:
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Email Address:
Phone number: Phone number: - ### - ### ####
Notice:

As a standardized patient you will be required to have initial and routine security background checks ran as part of your vendor agreement with the university.