Membership Application
Our members are the heart of the practice if Restorative Medicine. Together, we are a growing coalition of leaders confidently advancing restorative practices across the country.Join healthcare leaders from across the country as part of an unparalleled community of providers and allied health professionals, committed to leveraging ACRM connections and resources to provide exceptional health outcomes for your patients.
Membership Level Selection
Provider Membership (MD, DO, DC)
Advanced Practice Provider Membership (PA, NP)
Allied Health Professional Membership
Date of Application
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Month
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Day
Year
Date
Personal Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name as you want it to appear on your certificate.
Education Information (If Applicable)
Institution
Graduation Year
Degree Awarded
Please provide proof of graduation (diploma/transcript).
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Employment Information
Current Employer (RM Practice)
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of Employment
Individual Criteria Information
Education/Licensing Requirement
For Provider Members: I have earned an advanced degree (MD, DO, or DC) from an accredited institution.
For Advanced Practice Provider Members: I have earned an advanced degree from an accredited institution, possess and active certification from accrediting organization and licensures as appropriate for individual level (PA-C, FNP-C, etc.) and am actively employed in a practice that offers restorative medicine and that employs a member provider (DC, DO, or DC).
For Allied Health Professional Members: I am actively employed in a practice that offers restorative medicine and that employs a member provider (DC, DO, or DC).
Evidence for Satisfaction of Individual Criteria
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(Resume/CV, License, and/or Training Certificates)
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Attestation
By typing your name below, you attest that the information provided above is true and correct.
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