First Name
Last Name
Email
Nicknames used by patients? (Example: Your name is James Benjamin Smith, but you prefer to be called “Dr. Ben Smith, Dr. Ben, etc.”)
Phonetic tips for pronouncing your first and last name correctly? (Example: Alexis Walch = uh-LEK-sis WAWLCH)
Gender
Male Female Non-binary Genderqueer Other Decline
Pronouns
He/Him She/Hers They/Them Ze/Hir/Hirs Other Decline
Credential (per license)
MD
DO
APRN
PA
Certifications (Please list any/all certifications received including abbreviation and full certification name. Examples: DNP = Doctor of Nursing Practice, FNP = Family Nurse Practitioner, etc.)
Practicing Specialty (Family Medicine, Internal Medicine, Pediatrics, General Surgery, Cardiology, etc.)
What age range of patients do you see in your practice? (ex: newborn - 18, age 2-adults, 18 - adults, etc.)
Primary Language
Additional Language Proficiencies
Getting to know you questions
Please list information you are okay sharing with patients.
What made you become a provider?
What is your care philosophy/vision for your clinic? What do you want your patients to know about your practice?
What do you want your patients to know about you personally?
Do you have any interests outside of work that you’d like to share?
Boards/Committees at Memorial Health and/or within your community? (If possible, include boards/committees, positions held and years of service.)
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?
Any patients you feel particularly called to support from an EDI perspective? (i.e., patients with disabilities, autism, assistive device needs, transgender considerations, etc.?)
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.)
Yes No Unsure – I’d like more information before deciding. Prefer not to answer.
Are you comfortable discussing gender re-assignment? Hormone replacement therapy? Referring patients to the transgender clinic at SIU School of Medicine if appropriate?
Yes No Unsure – I’d like more information before deciding. Prefer not to answer.
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?
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.