Overview Video

Application Information

$200

To be considered, physician applicants must be board-certified within their practicing specialty and faculty members of major medical societies.

Activities representing faculty-level membership may include board membership on a medical society, and/or having a recent history of journalistic publications or podium presentations.

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 re-vetted annually to ensure quality requirements continue to be met.

 

Application Form





Specialty















National Provider ID Number:

Please list any medical societies you are a member of*

Please list any medical societies in which you sit on the board (or equivalent body)*:

Please list the titles of at least your last three presentations and dates*:

Please list your three most recent publications (if any):

Are you a consultant to industry?:


If so, please disclose the companies you have been a consultant for:

Credit Card Number:

Expiration Date:

Security Code (or “CVC” or “CVV”):

Billing ZIP Code*: