Phone: (316) 684-5500 Email: [email protected]

Join us for our 2019 Spring Meeting
Advanced Applications of IV Therapy
April 24 - 28, 2019


The Palomar Hotel
Phoenix, Arizona




AAEM Membership Application - Step 1 of 3

Please submit the form below. Asterisked (*) fields are required.


Membership:


* Membership Type

 


Name and Title:


     

* First Name

 

Middle Name or Initial

 

* Last Name

 

Title(s)

 

     

Business Information:


     

Business Name

 

* Business Address 1

 

Business Address 2

 

* Business City

 

* Business State

 

Non-USA State/Region/Province

 

* Business Zip / Postal Code

 

* Country

 

     

Contact Information:


     

* Business Phone

 

Business Fax

 

Mobile Phone

 

Home Phone

 

* Email Address

 

Website

 

http://

     

Personal Information:


     

Highest Education Level

 

Licensure

 

Attach CV

 

Attach Photo/Headshot (optional)

 
     

* Have judgments or verdicts been made against you in professional liability cases?

 

Yes
No

     

* Has your license to practice medicine or any other health care profession in any jurisdiction ever been suspended or revoked?

 

Yes
No

 

     

* Have you ever been denied membership, or renewal thereof, or been subject to disciplinary action in any medical organization or any other health care profession?

 

Yes
No

 

Please state your reason for wanting to join the Academy:

 
     

Certifications:


   

CERTIFICATIONS (check all that apply)

Allergy / Immunology

 

Anesthesiology

 

Colorectal Surgery

 

Dermatology

 

Emergency Medicine

 

Environmental Medicine

 

Family Practice

 

Internal Medicine

 

Neurological Surgery

 

Nuclear Medicine

 

Obstetrics / Gynecology

 

Ophthalmology

 

Orthopaedic Surgery

 

Otolaryngology

 

Pathology

 

Pediatrics

 

Physical Medicine / Rehabilitation

 

Plastic Surgery

 

Preventive Medicine

 

Psychiatry / Neurology

 

Radiology

 

Surgery

 

Thoracic Surgery

 

Urology

 

Other

 

     

Specialties:


   

SPECIALTIES (check all that apply)

Acupuncture

 

Adolescent Medicine

 

Allergy

 

Chelation

 

Clinical Immunology

 

Dermatology

 

Environmental Medicine

 

Family Practice

 

Homeopathy

 

Immuno-Metabolic Disorders

 

Internal Medicine

 

Non-Toxic Dentistry

 

Nutritional Medicine

 

OB/GYN

 

Otolaryngology

 

Pediatrics

 

Preventive Medicine

 

Psychiatry

 

Toxicology

 

Urology

 

Other

 

     

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