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New Provider Profile Form

Welcome to SIU Medicine!

Please fill out this form to provide the marketing team information for your online profile.

These profiles will be display on one or both of our websites; (patient audience) and (student audience). Therefore, it is important you fill this out as detailed as possible to provide your information and specialties to the correct audience. We will filter information based on the audience.

Please reach out to us with any questions.

This is typically Associate Professor or Assistant Professor - if you do not have a faculty appointment, please leave this field blank.
This is the clinic address where you will see patients. For example - 751 N Rutledge or Family Medicine - Taylorville
BILLING PROVIDERS ONLY: This is the title you give patients. For example: family medicine physician or registered dietician or pediatric surgeon


Below is a list of specialties. Please select all that apply 


Click here to view treatments and type all that you provide in the text area below

Provider Portrait

Click here to schedule your professional portrait with the SIU Medicine photographer.