Preceptor Information

PRECEPTOR ENROLLMENT

Please review the details of the Preceptor Agreement for the RSA Fellowship Network found at the following link: (Click Here to Download)

JULY 2021 thru JUNE 2022 (LEVEL 1 FELLOWSHIP)*

By completing the form below, I submit my enrollment as a Fellowship Preceptor and Founder in the RSA Fellowship Network spanning July 2021 thru June 2022. I have reviewed the Preceptor’s Commitment Letter Dated May 1, 2021, (Click Here to Download) and agree to its terms, and acknowledge that this is the inaugural year for the program. I understand this program provides each Fellow with a unique “networked” format for the fellowship and entitles them to participate in extensive training in a virtual environment, as well as access to electives at other RSA clinical sites and other programs. I further understand that my Enrollment Fee is non-refundable.

PRECEPTOR FEE (USD)

$0.00

I understand that this enrollment fee is displayed in USD and is non-refundable and non-transferable. I further understand that I am responsible for any additional fees/expenses which may be required to fulfill this application process.

PRECEPTOR INFORMATION

FULL NAME & CREDENTIALS:*

First Middle Last Credentials (MD, DO, MBBS, etc...)

Certifying Board*

Please provide the name of the board which awarded your certification(s). i.e. ABO for American Board of Ophthalmology or MBBS for Bachelor of Medicine, Bachelor of Surgery.

Academic Appointments (if Any)

Please provide any Academic Appointments, Titles, etc...if any

PERSONAL EMAIL:*

Enter Email Confirm Email

PERSONAL CELL PHONE NUMBER:*

PRACTICE / SITE INFORMATION

Practice Name*

PRACTICE ADDRESS:*

Street Address City State / Province / Region ZIP / Postal Code Country

ADMINSITRATIVE CONTACT @ PRACTICE*

Fellows Email Address*

Enter Email Confirm Email

PRACTICE PHONE NUMBER:*

PRACTICE WEBSITE:*

INCOMING 2021 FELLOW INFORMATION

FELLOW FULL NAME & CREDENTIALS:*

First Middle Last Credentials (MD, DO, MBBS, etc...)

Date of Birth*

Gender*

Administrative Contact Email Address*

Enter Email Confirm Email

Fellows Cell Phone*

Fellows Residency Program*

Please provide the full name of the Residency Program your Fellow attended.

ENROLLMENT & FEE SUBMISSION OPTIONS

METHOD OF PAYMENT FOR MY PRECEPTOR FEE*

Upon clicking the "Submit & Pay Preceptor Feeby Credit Card" you will be redirected to the PayPal website to pay your "Preceptor Fee".

BENEFICIARY / RECIPIENT INFORMATION:
The information below will allow you to make the wire transfer of the Preceptor Fee:

Beneficiary Name: Refractive Surgery Alliance Corporation
Beneficiary Address: 28071 North 90th Way Scottsdale, AZ 85262 USA
Beneficiary Bank: Wells Fargo Bank NA 420 Montgomery Street San Francisco CA 94104 USA
Beneficiary Account #: 1545479287
Amount to Transfer: $ 15,000.00 USD
Funds to be sent in: USD
ABA/RTN: 121000248
SWIFT Code: WFBIUS6WFFX
Memo Line: RSA Preceptor Fee Level 1

Upon clicking the "Submit & Pay Preceptor Fee by Wire Transfer" you agree to make a wire transfer of the Preceptor Fee within five (5) business days of submitting this Preceptor Enrollment.

BENEFICIARY / RECIPIENT INFORMATION: Please make your Preceptor Fee check payable to and mail to the following:

Make Chek Payable to: Refractive Surgery Alliance Corporation
Mailing Address: 28071 North 90th Way Scottsdale, AZ 85262 USA
Amount: $ 15,000.00 USD
Funds to be sent in: USD
Memo Line: RSA Preceptor Fee Level 1

Upon clicking the "Submit & Pay Preceptor Fee by Check" you agree to make payment of the Preceptor Fee by check within five (5) business days of submitting this Preceptor Enrollment.

Phone

This field is for validation purposes and should be left unchanged.

*

RSA Fellowship Network - Preceptor Enrollment

PRECEPTOR ENROLLMENT

PRECEPTOR INFORMATION

PRACTICE / SITE INFORMATION

INCOMING 2021 FELLOW INFORMATION

ENROLLMENT & FEE SUBMISSION OPTIONS

*