B2R Application & Payment Form

Please fill out application form details. Product selection and terms of agreement will be collected on the next step. Make sure all information is complete and accurate.

First Name *

Last Name *

Cell Phone *

Email *

Date of birth *

Do you currently reside in the US? *

Yes

Address *

Street Address *

City *

State *

Country *

Postal Code

Recent Photo *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Program Type *

* The Chief Assistant Physician (CAP) Program is available by invitation only. If you were not notified that you have been selected as a Chief Assistant Physician, please do not apply to this program.

Assistant Physician License # *

Certifications

If the Assistant Physician is a party to any other practice agreement(s), please list here:

Are you Currently Enrolled in Medical School? *

Yes

Certificate of Insurance (contact [email protected]) to obtain *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Cohort Year

Medical School

Year of Graduation

USMLE Step Score(s)

Have you failed any of your USMLE exams?

Yes

Explain your circumstances for why you did not pass the USMLE exam(s)

Clinical Experience

Upload your CV (optional)

PDF, DOCX or DOC

Select your program below. Please review the following:

If you were notified that you have been selected as a Chief Assistant Physician (CAP), please go ahead and purchase the Assistant Physician Program and your role will be upgraded automatically to CAP upon submission.
The externship program is an in-person program.
The virtual rotation program is a remote program.
The interview prep and personal statement review services are included in the AP, extern, and VR programs and do not need to be purchased separately.
Please DO NOT sign up and pay for the B2R Assistant Physician Program if you do not currently have an active Assistant Physician License in the State of Missouri. The sign up fee is non-refundable.

Program Selection: *

Bridge to Residency (B2R) Assistant Physician Program

$250

Bridge to Residency (B2R) Externship Program

$500

Bridge to Residency (B2R) Virtual Rotation

$500

Residency Interview Preparation

$200

Residency Personal Statement Review

$200

By checking this box, I agree that my application process is not fully complete until I sign the relevant B2R Agreement form that will be emailed to me upon submission of this application. I must sign the contract by May 1st to be allowed access to the program.

By checking this box, I consent to receive non-marketing text messages from The Medina Clinic about the Bridge 2 Residency program and communications with the team. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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