Membership Application

I am *

An Orthopedic Executive - Membership Fee - $100.00

First Name *

Last Name *

Medical Group Name

Office Street Address (No P.O. Box please) *

City *

State *

Zip Code *

E-Mail: *

Phone Number *

Fax Number

Type of Practice *

Private Practice

Hospital-Owned Group

ACO ACO

EMR System

Number of Practice Locations

Practice Management System

Name of Orthopaedic Surgeons in Your Group *

Name of Physicians/Podiatrists in Your Group

# of Physical Therapists

# of Medical Assistants

# of Nurse Practitioners

# of Occupational Therapists

# of Physician Assistants

# of Athletic Trainers

# of Cast Techss

Other:

In-Office Ancillary Services (check all that apply)

Payment Method *

Credit Card (3% surcharge will be added)

Check