Apply for Registration

$200

To be considered, physician applicants must be board-certified within their practicing specialty and and must have a recent history of journalistic publications in medical journals.

All applications are subject to a vetting and approval process reviewed by a group of peer physician members.

A $200 application fee is required. Upon submission, your credit card will be charged.

All members will be required to re-apply annually to ensure quality requirements continue to be met.

Application Form

Name *
Name
Practice Address *
Practice Address
Cell Phone *
Cell Phone
Are you a consultant to industry? *
The 16 digits on the front of your credit card
The date your credit card expires. You will find it on the front of your card.
The last 3 digits displayed on the back of your credit card
Your zip/postal code as it appears on your credit card statement
Section
By initialing below, I authorize CONCIERGE KEY Health, LLC to store and charge this card for future purchases as agreed until I cancel this authorization. I understand I will be charged $200 now, and if my application is approved, will receive a Membership. I understand that my Annual Membership term begins now and lasts one (1) year, or until December 31, 2018, whichever is later. I also understand that I will need to re-apply on every anniversary to remain a Member, and such re-application will have a $200 application fee.
MEMBERSHIP TERMS *
By checking this box, I acknowledge that I have read and understand the CONCIERGE KEY Health Terms of Service.