First Name
This field is required
This field needs to be a valid value
Last Name
This field is required
This field needs to be a valid value
Email
This field is required
Email needs to be a valid email address.
Nicknames used by patients? (Example: Your name is James Benjamin Smith, but you prefer to be called “Dr. Ben Smith, Dr. Ben, etc.”)
This field is required
This field needs to be a valid value
Phonetic tips for pronouncing your first and last name correctly? (Example: Alexis Walch = uh-LEK-sis WAWLCH)
This field is required
This field needs to be a valid value
Gender
This field is required
Pronouns
This field is required
Credential (per license)
MD
DO
APRN
PA
This field is required
Certifications (Please list any/all certifications received including abbreviation and full certification name. Examples: DNP = Doctor of Nursing Practice, FNP = Family Nurse Practitioner, etc.)
This field is required
Practicing Specialty (Family Medicine, Internal Medicine, Pediatrics, General Surgery, Cardiology, etc.)
This field is required
This field needs to be a valid value
What age range of patients do you see in your practice? (ex: newborn - 18, age 2-adults, 18 - adults, etc.)
This field is required
This field needs to be a valid value
Primary Language
This field is required
This field needs to be a valid value
Additional Language Proficiencies
This field is required
This field needs to be a valid value
Getting to know you questions
Please list information you are okay sharing with patients.
What made you become a provider?
This field is required
What is your care philosophy/vision for your clinic? What do you want your patients to know about your practice?
This field is required
What do you want your patients to know about you personally?
This field is required
Do you have any interests outside of work that you’d like to share?
This field is required
Boards/Committees at Memorial Health and/or within your community? (If possible, include boards/committees, positions held and years of service.)
This field is required
Special Interests/EDI Considerations
Consider the types of patients you enjoy working with. This does not mean that you have special courses or received any special training, per say. Think about this in terms of the types of patients, ailments, issues you enjoy assisting patients with – i.e. diabetes management, weight management, disabilities, etc. This is a way for patients to research and identify if you will be a good fit for them.
What types of illness/injuries/ailments do you enjoy working through with patients?
This field is required
Any patients you feel particularly called to support from an EDI perspective? (i.e., patients with disabilities, autism, assistive device needs, transgender considerations, etc.?)
This field is required
To better serve our patients, Memorial is compiling a list of physicians who are comfortable caring for LGBTQ+ patients both in terms of their general health and in terms of discussing their sexual orientation and gender identity in an affirming way. A “safe-space” designation may be added to your website profile. This would tell a patient you are comfortable having discussions around this topic in a sensitive and affirming way. Would you like this safe space designation for your clinic when this is available? (Note: This may require training for clinic staff to ensure comfort for patients at ALL aspects of the clinic from registration to the physician visit.)
Would you like this safe space designation for your clinic? (Note: This may require training for clinic staff to ensure comfort for patients at ALL aspects of the clinic from registration to the physician visit.)
This field is required
Are you comfortable discussing gender re-assignment? Hormone replacement therapy? Referring patients to the transgender clinic at SIU School of Medicine if appropriate?
This field is required
Is there any additional information you would like to share or you think would be beneficial for patients as they establish care at your practice?
This field is required
Thank you for your time in providing this information. When finished, click submit and your responses will be sent directly to our patient experience team.