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Home  >  Physician Web Directory  >  Physician Web Directory Input form

Georgia Regents Health System Physician Web Directory Input Form

All fields that are marked with * must be completed.
Please send a digital photo in jpg format to [email protected].

First Name  *Middle Initial or Name Suffix (Jr., III, etc.): Last Name  *Degree (MD, DDS, etc.):  *Administrative title: Faculty title: Faculty rank: (Professor, Associate Professor, etc.) Practice Name:
(If other than GR Health System) E-mail address: (will not be displayed on website)  *Affiliations:  *
Georgia License #:  *GRHealth Staff ID #:  *

Office Location #1

Office address #1:  *Building: Suite #:  *City  *State  *Zip Code  *Appointment Phone  *Office Phone (will not be displayed on website)  *

Office Location #2

Office address #2: Building: Suite #: City: State Zip Code Appointment Phone: Office Phone: (will not be displayed on website) 

Office Location #3

Office address #3: Building: Suite #: City: State: Zip Code Appointment Phone: Office Phone: (Will not be displayed on website) 

Specialty (please select at least one)

Specialty #1:  *Specialty #2: Specialty #3: 

Board Certifications

Board Certified?  *
Certification #1: Certification #2: Certification #3: 

Languages Spoken

Main #2: #3: 

Clinical Area of Interest

(2500 character limit) 

Research Interest

(2500 character limit) 

Education

(Please give complete name of school and year completed.) Medical School:  *Internship: Residency: Fellowship: 

Short Biography

(5,000 character limit)  Your information will take a moment to process. To avoid duplicate submission, please do not click on the back button or hit submit more than once.