Fast Track to MD

Student Intake Form

Dr. Ruwaa Samarrai, MD — Mentorship & Application Strategy

Confidential · For Session Preparation Only

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 — Session Goals

What is your single most pressing question or concern going into this session? *

What would make this session a success for you?

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 session.

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Form Received

Thank you — Dr. Samarrai will review your profile before your session. You'll receive a scheduling confirmation shortly.