Pre-Application Form - Palmdale Regional Medical Center 2026

1. Click ‘Get Form’ to open the Pre-Application Form in our editor.
2. Begin by filling out the 'Personal Information' section. Enter your last name, first name, date of birth, place of birth, middle initial, social security number, office address, phone numbers, home address, and email address.
3. Indicate your clinical specialty and any areas where you wish to request clinical privileges. Ensure all fields are completed accurately.
4. In the 'Certification' section, specify if you are board certified. If yes, provide the name of the board and certification dates. If not certified, explain your status in the certification process.
5. List all hospitals where you have held clinical privileges in the last five years under 'Professional Information'. Include hospital names, addresses, dates of affiliation, and reasons for leaving.
6. Address any disciplinary actions in the relevant section. Answer truthfully and provide explanations on a separate sheet if necessary.
7. Attach required documents as listed at the end of the form before submitting it to Kirsten Webb at Palmdale Regional Medical Center.

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