Provider Profile

The following information is being collected in an effort to improve the patient experience and make better patient/provider connections when establishing care. This information will be use to update provider profiles on our website, as well as aid in discussions with patients who inquire about a new provider. Our goal is for better, long-lasting patient connections. For some patients, language may be more important than location. For others, a provider's practice philosophy may be the key factor in selecting a provider.

Thank you for taking the time to complete this form, which will be provided to our patient experience department.

First Name

Last Name

Gender Male
Female
Other

Credential (per license)

Certifications (Please list any/all certifications received (examples: DNP, FNP, FSCAI, 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

Languages Spoken

Special Interests in Your Practice

This does not mean that you have special courses or received any special, per say. Think about this in terms 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 illnesses/injuries/ailments do you enjoy working through with patients?

Getting to know you questions

What made you become a doctor?

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? (If possible, include boards/committees, positions held and years of service.)

EDI Considerations

Any patients you feel particularly called to support from an EDI perspective? (i.e., patients with disabilities – autism, assistive device needs, transgender considerations?)

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 can be added to your website profile. This tells patients you are comfortable having discussions around this topic in a sensitive way. 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

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

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.