Membership Application

Physicians - Please fill out the form below. Alternately, you may download and print the Membership Application, but you are not required to do both.
(Note: Be sure to only click the 'Submit' button once.)

Medical Students/Residents - Please click here.

Personal Information

First Name *

Last Name *

Email Address *

Billing Address *

City *

State *

Zipcode/Postcode *

Country *

Employer *

Specialty *

Billing Information

Name on Card *

Card Number *

Card Expiration *

Card Type *

CCV Number *

Membership Information

Please enter a username and password below so you can access the secure member area of our website.

Username *

Password *

Confirm Password *

*Please Select your Membership Level:

Gold and Active membership relate to the support levels of membership. In order to maximize our influence and meet our society objectives, we hope for your gold membership today.

Gold Membership ($1000 annually)
Gold Membership ($250 quarterly)
Active Membership ($250 annually)
Retired Physician ($100 annually)

Would you like to make an additional donation?
If so, please enter the amount below and it will be added to your transaction. Thank you!
$

Total Amount *
$

Please review this amount before submitting to verify that it reflects the Membership Level & optional Contribution Amount you've requested. You may change this amount by checking & unchecking the appropriate boxes.

To complete your payment, click 'Submit' ONLY ONCE. Your transaction may take a few seconds, so please be patient. Clicking 'Submit' will process the above total based on the payment and billing information provided. Thank you.

Please Note:
Membership Disclaimer:
Docs 4 Patient Care is a 501(c)(6) corporation. Docs 4 Patient Care physician membership dues are not deductible as a charitable contribution for federal income tax purposes. However, they may be partially deductible as a business expense. Please consult your professional tax advisor for the most up-to-date information concerning your specific tax status. Contributions by non-members are not tax deductible except by certain criteria, which should also be discussed with your professional tax advisor.