Pay Your Fees for Medical Staff Membership Online
Your Information
*
information is required.
Title
Please Select
Mr.
Ms.
Mrs.
Dr.
First Name*
Middle Name*
(if no middle name, type "none")
Last Name*
Name of Practitioner for Whom Payment is Made
Same practitioner name as on credit card
Phone*
Fax
Email Address*(For receipt purposes)
Payment Type
Please choose your payment type and
fill in the details for your chosen type.
Application Fee
Please Select
Physician, Dentist or Podiatrist - $300
Post-Doctoral Training - $300
Allied Health Staff (PA, NP, Perfusionist, etc) - $150
Annual Dues
Please Select
Physician, Dentist or Podiatrist - $250
Allied Health Staff (PA, NP, Perfusionist, etc) - $150
Reappointment Fee - $150
Other
Description
Amount $
Accept Credit Cards
Programming by
Morgan Multimedia, Inc.
Morgan Multimedia, Inc.Morgan Multimedia, Inc.