Legacy Health

As Legacy's link to the community, it is important that Legacy Referral Services has current and accurate provider information. Please take a few moments to complete this questionnaire. If you have questions, please contact us by email at LRS@lhs.org or call 503-335-3500 (Oregon) or 360-487-3500 (Washington).
* Required


Provider Information














Good Samaritan
Emanuel
Meridian Park
Mount Hood
Salmon Creek
Randall Children's Hospital

Education and Training

Please list the institutions at which you completed your professional training. Leave blank any categories that don't apply.









Specialties/Subspecialties











Practice Information





Accepting new patients?
Accept walk-ins?
Accept same-day appointments?
Accept children? (0-17)
Accept adults? (18+)
Offer free "get to know you" visit for prospective patients?


Primary Office Address















Secondary/Additional Office Address

















Website Photo

If you wish to have a photograph of yourself on our website, please e-mail a high resolution, professional studio quality image (in .jpg format) to Legacy Creative Services at creative@lhs.org. If you are a Legacy employed physician and don't have access to a recent photo, please contact your office manager to arrange a photo shoot.

Diversity

Legacy Health is committed to providing a welcoming environment for all our patients and their families. We strive to deliver care in a way that is sensitive to and respectful of the diverse backgrounds and unique needs of our patients. We understand that selecting a provider is an important decision and some patients express a preference for physicians with common backgrounds or specific demographics. Therefore, we offer a voluntary section that allows you to provide information that may assist our patients in their physician selection. Completion of this section is voluntary and will not affect the amount of referrals you receive. Legacy Health does not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status or any other basis protected by law. You can find further information about our diversity efforts at www.legacyhealth.org/diversity or by contacting our Director of Diversity Sheila Murty-Job at smurty@lhs.org or 503-415-5017.


Thank You

Thanks for providing your information. Provider profiles are processed in the order they are received. Please allow a minimum of 2 weeks for processing. If you have questions, please contact us by email us at LRS@lhs.org or call 503-335-3500.

Never submit passwords through Google Forms.