New Provider Intake — Rancho Health

Provider Information

Basic details for the website profile

* Required fields

First Name *

Last Name *

Credential / Degree *

Other Credential (if Other above)

Specialty / Clinical Focus *

Primary Care

Family Medicine

Internal Medicine

Geriatrics

Women's Health

OB/GYN

Obstetrics

Gynecology

Midwifery

Maternal-Fetal Medicine

Behavioral Health

Individual Therapy

Couples Therapy

Family Therapy

Child & Adolescent Therapy

Trauma & PTSD

Anxiety & Depression

Substance Use / Addiction

Other

Clinic / Brand *

Start Date (approximate)

Clinic Manager Name *

Manager Email *

Education & Training

Academic and clinical background for the provider profile

Undergraduate Institution *

Undergrad Degree / Major

Medical / Graduate School *

Med School Graduation Year

Residency Program *

Residency Specialty

Fellowship Program (if applicable)

Fellowship Specialty (if applicable)

Board Certifications (if applicable)

Languages Spoken (besides English)

Provider Bio & Personal Story

Used verbatim (or lightly edited) on the website provider profile

Why Medicine?

What drew them to healthcare? A personal story, a mentor, a defining moment?

Care Philosophy

Holistic, collaborative, data-centered, patient-led, preventive, relationship-based?

Outside the Clinic

Hobbies, family, passions, community ties — what makes them human.

Provider Bio * — 1 to 2 paragraphs, written in 3rd person (e.g. "Dr. Reyes…")

Tip: tap the mic to dictate — it works great on mobile.

Hobbies & Interests (short list for the website sidebar)

Additional Notes for Marketing (anything else the web team should know)

Review Submission

Confirm everything looks right, then export as PDF to email marketing