Find A Doc Data Sheet Form for Community Providers

The following form is for providers at Upstate Community Hospital who are not employees to be included in the Find A Doctor system.

*=required

Provider Basic Information

*First Name

*Last Name

Mid. Init.

*Clinical Degrees (MD, DO, PA, NP, etc.) (Type and select as many as needed)

*Upstate University Clinical Department/Division Affiliation (if applicable) (Type and select)

*Email (will not be displayed publicly) (user@place.com)

Office Address/Building Name

Room Number

City

State

Zip Code

*Phone Number (for the public directory)

Fax Number

*Do you Require Referrals?
Yes No

*What Hospital Campus are you Associated with?
Downtown Community Both

If Both, which one is the Primary Campus?
Downtown Community

Office Contact for Questions (name/phone)

Education / Residency / Fellowship

*Medical School

*Graduation Year

*Degree Awarded

Internship

Completion Year

Residency

Completion Year

Fellowship

Completion Year

Fellowship

Completion Year

Specialties/ Diseases / Treatments

*Specialties and Certifications

*Diseases and Conditions

*Treatments and Services

*Treats
Adults Children Adults & Children

Other Information

Associations/Memberships

Languages Spoken (Other Than English)

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