Provider Profile

We are asking you to provide the following information as part of our effort to improve the patient experience and build stronger relationships between patients and their medical providers. Our Patient Experience and Equity, Diversity & Inclusion departments will use the information to update provider profiles on our website, as well as to connect new patients with the provider who can best meet their unique needs.

Thank you for taking the time to complete this form.

All fields with asterisk next to them are required.  

Getting to know you questions

Please list information you are okay sharing with patients.

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.

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.)

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.