Fast Track to MD

Student Intake Form

Dr. Ruwaa Samarrai, MD — Mentorship & Application Strategy

Request Your Free Strategy Call

01 — Student & Family Information

Student First Name *

Student Last Name *

Parent / Guardian Name

Best Contact Email *

Current Grade / Year *

State of Residence

02 — Academic Profile

Current GPA (Unweighted)

Current GPA (Weighted)

SAT Score (if taken)

ACT Score (if taken)

AP Courses Taken / Planned — Enter Score (1–5) or leave blank if not taken

AP Course

Score

AP Biology

AP Chemistry

AP Calculus AB

AP Calculus BC

AP Physics

AP English Lang or Lit

AP Statistics

AP Psychology

Other (list below)

List any additional AP courses in the notes section at the end.

Dual Enrollment Courses Completed

03 — Pathway Goals

Primary Pathway Interest *

BS/MD or BA/MD Direct Entry Program BS/DO Accelerated Program Early Assurance Program (EAP) in Undergrad 3-Year Undergrad + Traditional Medical School CAMPP / 3-Year Medical School Traditional 4-Year Premed Pathway Not Sure — Need Guidance

Intended Major or Field of Study

Specialty Interest (if any)

College List — Schools Applied to or Considering

04 — Clinical & Research Experience

Clinical Shadowing or Volunteering

Research Experience

Extracurricular Activities & Leadership

05 — Investment & Timeline

How much are you willing to invest to become a doctor early? *

Under $500 $500 to $2,000 $2,000 to $5,000 $5,000 to $10,000 More than $10,000

There is no wrong answer. This helps me recommend the right level of support on our call.

How soon are you able to get started? *

Right away Within 2 weeks Within 1 to 2 months In 3 months or more Just exploring for now

06 — Your Goals

What is your single most pressing question or concern right now? *

What would success look like for your student?

How did you find Fast Track to MD?

Instagram Newsletter Reddit YouTube Referral Purchased a Course Other

Additional Notes

Your information is kept strictly confidential and used solely to prepare for your call.

✓

Request Received

Thank you. Dr. Samarrai will review your student's profile and email you a link to book your strategy call. Watch your inbox, and check spam, for a message from mdnow@fasttracktomd.com.