Provider Profile Questionnaire

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Thank you for joining NorthLakes!

This form helps us create your professional profile for our website, patient communications, and marketing materials. The information you provide will help patients become familiar with you and understand your approach to care before they visit. Your responses will be used for:

• Provider profile page on our website

• Social media and advertising promotion (various positions)

• Press releases announcing your arrival (when applicable)

Please take a few minutes to complete all fields below. Write your responses as you'd like them to appear publicly. Once submitted, our marketing team will review your information and may contact you if we need any clarification.

Name(Required)

As you would like it to be appear online and within marketing materials.

Email(Required)

Education(Required)

List your degrees and the educational institutions, as well as your residency details, if applicable.

Professional Interests & Philosophy of Care(Required)

Please answer in complete sentences.

Personal Interests

Please answer in complete sentences.

What advice would you give patients?

Please answer in complete sentences.

Languages(Required)

What languages do you speak, and at what level. Please describe.

Questions?

Contact marketing@nlccwi.org