The National Foundation for the Treatment of Pain

Membership

Physicians' Membership Application

   First Name   Last Name

Organization

Address

City    State

Zip/Postal Code    Country

Phone

FAX

e-Mail

Fee: $100 annually

Choose one:

Card Number

Expiration Date   (mm/dd/yyyy)

Date of Birth   (mm/dd/yyyy)

Medical Specialty

Board Certification

Board Eligibility

Medical School

Date of Degree   (mm/dd/yyyy)

Internship

Residency

Pain Treatment Experience

States in which you have held a medical license

Hospitals, with mailing address, at which you currently hold staff privileges

Check all that apply:

I am willing to comprehensively treat pain patients.

I am prepared to appropriately refer pain patients for indicated services.

I am expert in the management of pain though medication.

I will accept referral of patients from the National Registry.

I am committed to seeking the highest level of function
      for intractable pain patients

Comments:

By entering my full name and clicking "Submit", I herewith permit the National Foundation for the Treatment of Pain to make necessary inquiries to verify the information I have provided.

Agree:

(Please enter full legal name)

The National Foundation for the Treatment of Pain
P.O. Box 70045 ~ Houston, Texas 77270-0045
Phone: (713) 862-9332 ~ FAX: (713) 862-9346

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