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"*" indicates required fields

Please enter an email to receive information regarding your profiles progress. The email entered in this field is strictly for communication purposes should we have a question about your form submission.
Which are you doing today?*
* If you currently have a profile and recently had a name change, please select the update option. Creating a new profile will result in duplicate profiles for you. Thank you.
What type of profile is this?*

Please provide as much information as possible for the new profile.

Please provide only the information that is to be added or changed after completing the required fields.

Please provide the name of the individual whose profile needs to be removed from the BCH and Alliance website.

This field is hidden when viewing the form

Section Break

Please use the following format: Title, Practice (ex. Pediatrician, ABC Pediatrics or Nurse Practitioner, ABC Pediatrics)

If you hold multiple titles, please separate by semicolon ;
The phone number provided in this field will be published to your public profile. Please do not include any personal phone numbers.

It is recommended the phone number submitted be of your respected Department/Division/Center/Program.
Does your business card information differ from the above?*

If you have selected No, please scroll to the bottom of this form for additional business card edits.

Multi-Select Instructions

To select more than one specialty, department, program and languages, hold control or command and click on desired selection.
Please only include completed board certifications. If there is a sub-specialty missing from this list, please make note in the instructions below. * At this time we are not accepting international certifications.
* Conditions treated or procedures performed.Please make sure any condition you submit has a corresponding condition or treatment page: http://www.childrenshospital.org/conditions-and-treatments

To select more than one specialty, department, program and languages, hold control or command and click on desired selection.

Please limit 10-15 specialties. We will not publish to your profile is more than 15 are submitted. Thank you.
If your language does not appear in the list below, please request your language at the end of this form in the Notes/Instructions field.

To select more than one specialty, department, program and languages, hold control or command and click on desired selection.

Additional Items Instructions

To add additional locations, medical schools, residencies, and fellowships, click the plus sign next to the desired selection.
Undergraduate School
School Name
City
State
Date
 
Graduate School
School Name
City
State
Date
 
Medical School
School Name
City
State
Date
 
Internship
School Name
City
State
Date
 
Residency
School Name
City
State
Date
 
Fellowship
School Name
City
State
Date
 
Please provide a brief philosophy of care; this could include why you entered medicine or your approach to your practice. (Please keep to between 300-400 max characters).
Please describe your professional history below in paragraph form (limit ~200 words). Please submit Professional History in 3rd person.
Please make sure your image is uploaded as lastname-firstname.jpg. For your convenience, headshots will be scheduled with an on-site visit. More information coming soon.

Thank you.
Accepted file types: jpg, png, Max. file size: 5 MB.
All images must be high resolution and brand compliant.
Please see brand guidelines for full details on brand compliant imagery. Use the plus sign to add additional images if applicable.
Accepted file types: jpg, png, Max. file size: 5 MB.
>> Any condition submitted must have a related condition or treatment page:
http://www.childrenshospital.org/conditions-and-treatments

We are unable to include a specialties or programs that are not listed on either of the links above.



* Upon completion and submission of this form, your profile request will be created or updated within 10 business days.
This field is for validation purposes and should be left unchanged.

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  • Web Content Updates
    • Submit a Remedy Ticket
    • Headshot Information
    • For Clinicians
      • Create or Update a Profile
      • Online Reputation
      • New Clinician Checklist
    • For Reseachers
      • Researcher Profile
      • Create a Lab Website
  • Website Training
    • Standard Editor Training
    • Premium Editor Training
  • Marketing Communications
    • Communication Requests
    • Video Request
    • Video Edit Request
    • Headshot Information
  • Web Content Updates
    • Submit a Remedy Ticket
    • Headshot Information
    • For Clinicians
      • Create or Update a Profile
      • Online Reputation
      • New Clinician Checklist
    • For Reseachers
      • Researcher Profile
      • Create a Lab Website
  • Website Training
    • Standard Editor Training
    • Premium Editor Training
  • Marketing Communications
    • Communication Requests
    • Video Request
    • Video Edit Request
    • Headshot Information