Onboarding / Departing Provider(s)?

Onboarding / Departing Provider(s)?

Please ensure to complete a "Add New Listing" (ONBOARDING) or "Remove or Edit an existing Google Listings" (DEPARTING) ticket after submitting this form.

Your Contact Information

Provide your contact information in this section in case we have questions.

Submission Date*

Today's Date

HMD Name*

Hospital*

HMD Email*

Provider Information Begins Here

Onboarding or Departing?*

Do you have a provider onboarding or departing?

Select

Effective Date*

When will the provider start or term?

Provider Name*

Please add the provider's name and/or credentials

Is this provider board certified?*

Clinic or Provider-Based (Hospital)*

Will this provider be a part of a clinic entity or will they be part of a provider-based (hospital) entity?

Select

Physician Group Name*

Specialty*

Contact Number*

Address *

Physician Group Bio*

Provide as much information as possible including education, background, and a short paragraph about getting to know the provider.

Services and/or Conditions Treated

Bullets of services offered or conditions treated. Please be consistent and use either, or.

Attachments

Attach a provider headshot that is at least 300 pixels wide and more than 300 pixels high at 100 dpi. Standard background preferable but not required. Also, attach any additional content you might want to include in the profile.

Drag and drop files here or

Video

Do you have a Video profile for this provider?

Will this impact a service line?

Will the departing provider cause disruption to a service line? aka - if you only have (1) provider for ortho services and they are leaving, how will this impact services? Do you have a new provider coming on board, etc.?

Select

Website Ticket Submitted?*

Please submit a website ticket at QuorumHelp.com to have the provider or service line added or removed.

https://quorumhelp.com/

Yes

Link to new/departing provider / service line page*

Please add the link to the new/departing provider/service line page. If the new provider link is not ready please specify this below.

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