UHS Membership Application Form

UHS Membership Application Form

Please fill in the form below.
Full Name*

PrefixFirst NameLast Name
Practitioner Organization
Practitioner Type & Credentials
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
How Did You Hear About UHS*
If Referred By Someone, Please List His/Her Name:
Registration Type*
prevnext( X )
2020 Practitioner UHS Membership$65.00

Total $0.00
Please contact the UHS office with questions, info@uhsmi.com.
Should be Empty: