First Name
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Last Name
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Nicknames used by patients? (Example: Your name is James Benjamin Smith, but you prefer to be called “Dr. Ben Smith, Dr. Ben, etc.”)
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Phonetic tips for pronouncing your first and last name correctly? (Example: Alexis Walch = uh-LEK-sis WAWLCH)
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Gender
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Pronouns
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Credential (per license)
MD
DO
APRN
PA
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Certifications (Please list any/all certifications received - examples: DNP, FNP, FSCAI, etc.)
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Practicing Specialty (Cardiology, ENT&A, Pulmonology, General Surgery, etc.)
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What age range of patients do you see in your practice? (ex: newborn - 18, age 2-adults, 18 - adults, etc.)
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Primary Language
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Additional Language Proficiencies
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Getting to know you questions
Please list information you are okay sharing with patients.
What made you become a provider? (and/or) What interested you about this particular specialty?
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What is your care philosophy/vision for your clinic? What do you want your patients to know about your practice?
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What do you want your patients to know about you personally? (Note: This could be a number of things: Fun facts, your background, connections to the area, more about your practice philosophy, etc.)
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Do you have any interests outside of work that you’d like to share?
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Do you serve on any boards/committees at Memorial Health and/or within your community? (If possible, include boards/committees, positions held and years of service.)
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About Your Practice/Area of Specialty
What types of procedures do you most commonly offer in your practice?
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What types of conditions/ailments do you commonly treat in your practice?
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Do you currently have any outreach/satellite locations in other communities?
Yes
No
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(If Yes, please provide the city, location and dates clinic/outreach is scheduled in that community.)
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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.
Think about this in terms of the types of patients, ailments, issues you enjoy assisting patients with as part of your specialty and practice. 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?
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Are there any patients you feel particularly called to support? (i.e., patients with disabilities, autism, assistive device needs, transgender patients, etc.)
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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? (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.)
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Additional Information
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?
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Thank you for your time in providing this information.