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Personal Detail

First Name

Middle Name

Last Name

Degree

Date of Birth

Suffix

Gender (for statistical purposes only)

Address

City

State

Zip

Home Phone

Cell Phone

Office Phone

Fax

Practice Detail

Practice Name

Practice Address

Practice City

Practice State

Practice Zip

Practice Website

Practice Setting

Urgent Care Center

Solo Private Practice

Group Private Practice

Hospital-Based Urgent Care

Emergency Department

Military

Other

Practice Setting (Other)

Are you the practice owner?

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Education

Name of Medical/Osteopathic/Physician Assistant/Nurse Practitioner School

Did you complete a residency?

Yes No

If yes, in what specialty(ies)?

Are you Board Certified?

Yes No

If yes, in what specialty(ies)?

List All The States and License Numbers In Which You Are Licensed:

Payment

Membership Type

Physician - $325.00

Physician Assistant - $325.00

Nurse Practitioner - $325.00

Senior (over 65) - $175.00

Lifetime - $2000.00

Diplomate - $200.00 (Board Certified by the American Board of Urgent Care Medicine)

First Name on Card

Last Name on Card

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Expiration Year

CVV

Billing Address

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Member Center Account

Password

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