New Listing Form

New Listing Form

This is where you start the process for getting a listing for a physician or practice. If you already have a listing and only need changes, please submit them through the quorum web ticket submission form.

Todays Date*

HMDs Name*

Practice or Provider Name:*

Be sure to type this out EXACTLY as you want it to appear in the listings. PRACTICE EXAMPLE: Crossroads Community Urgent Care PROVIDER EXAMPLE: Joe K. Smith, M.D., FACS

Provider First Name*

Sorry if this is redundant but we need this information entered into the system separately

Provider Middle Name or Initial

Sorry if this is redundant but we need this information entered into the system separately

Provider Last Name*

Sorry if this is redundant but we need this information entered into the system separately

Provider NPI Number*

Practice Name*

Please provide this for both provider and practice listings.

Street Address:*

It's also important to type this out exactly how you want it to appear on Google. Variations in abbreviations from what you have on your website may cause confusion in the future.

Address 2:

Suite Numbers

City*

State*

Please use the two-letter abbreviation for your state. Like the post office uses. EXAMPLE: California = CA

Fax Number for Practice or Provider

Phone Number for Practice or Provider*

Provider or Practice?*

Provider = Person Practice = Location

Select

Postal Code*

Website*

For a Provider, use the Full Link to his/her profile on your practice site. EXAMPLE: https://oregonheartdoc.com/providers/tushar-tuliani-md/ For a Practice, use the home page of your practice site. EXAMPLE: https://threeriverssurgery.net/

Please upload professional headshot below

Make sure file is saved as the providers name please.

File Upload

Drag and drop files here or

Monday Opening Time*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Monday Closing Time*

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Tuesday Opening Time*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Tuesday Closing Time

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Again, please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Wendesday Opening Time*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Wednesday Closing TIme*

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Again, please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Thursday Opening Time*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Thursday Closing Time:*

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Again, please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Friday Opening Time:*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Friday Closing Time:

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Again, please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Saturday Opening Time:*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Saturday Closing Time:*

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Again, please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Sunday Opening Time:*

Please use military time format: EXAMPLES: 8 am = 8:00 11 am = 11:00 IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Sunday Closing Time:*

Please use military time format: EXAMPLES: 5 pm = 17:00 7 pm = 19:00 Again, please DO NOT list times when the office is "closed for lunch" IF NOT OPEN ON THIS DAY, PLEASE STATE: Closed

Hospital Name and Descriptor*

Choose the proper designation from the options below:

Select

Restroom Available

Select

TeleHealth Appointments Available?

Select

Wheelchair Accessible Elevator?

Select

Wheelchair Accessible Entrance

Select

Wheelchair Accessible Restroom?

Select

Open 24 Hours?

Select

Provider Gender

Only if this is for a single provider and not a practice or location.

Select or enter value

Specialty*

Select or enter value

Secondary Specialty

Select or enter value

Appointment URL

Please use the providers' profile address. EXAMPLE: https://eastarkansascare.com/providers/womens-health-providers/robert-chin-md/ For Practices/Locations, use the main Provider Site URL: https://eastarkansascare.com or your ANYTIME SITE https://forrestcityanytime.com/

Is this a Provider Listing?*

Is this listing for a single provider?

Select

Is this a Location/Practice Listing?*

Select

Date Needed to Go Live

Why is the doctor needing to go live later than expected?

Send me a copy of my responses

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