Ouachita Medical Society Membership Application

Membership Application
Full Name

First NameMiddle NameLast NameSuffix
Name As You Would Like It Listed
Headshot for Physician Directory

Cancelof
Preferred Name or Nickname (if different from First Name)
LA License #
EDUCATION
Undergrad

Graduation Year

School Name

CityState / Province

Postal / Zip CodeCountry
Medical School

Graduation Year

School Name

CityState / Province

Postal / Zip CodeCountry
Degree:
Residency

Year Completed

Location

CityState / Province

Postal / Zip CodeCountry
Fellowship (if applicable)

Year Completed

Location

CityState / Province

Postal / Zip CodeCountry
Fellowship Subspecialty
PERSONAL INFORMATION
Gender
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState

Zip
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Personal Email
example@example.com
Spouse's Name (if applicable)
PROFESSIONAL INFORMATION
Primary Specialty
Secondary Specialty (if applicable)
Work Address

Business/Practice Name

Street Address

CityState

Zip
Office Phone
Format: (000) 000-0000.
Office Fax
Format: (000) 000-0000.
Work Email
example@example.com
Website
Office Manager/Other Contact: Name
Office Manager/Other Contact: Email
example@example.com
Membership
Membership Type (select one):
Payment (select one):
CLICK HERE TO PAY DUES ONLINE
Disclosures

Members are governed by the Ouachita Medical Society (OMS) Principals of Medical Ethics and must comply with the bylaws of the OMS. To assist in upholding these standards, please provide answers to the following questions.
Have you ever been convicted of fraud or a felony?
Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any imposed sanctions or conditions.
Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?
If you answered yes to any of the above 3 questions, please explain fully below and forward any relevant information/documentation to director@ouachitams.org.
Signature
Date

MonthDayYear
REFERRAL
If membership was recommended to you by an OMS member, please list his/her name.
MAILING
If paying by check, completed application and payment can be mailed to:

Ouachita Medical Society, P.O. Box 2884, Monroe, LA 71207

If paying by credit card, completed application may be scanned and emailed to: director@ouachitams.org
Should be Empty:

Membership Application

EDUCATION

PERSONAL INFORMATION

PROFESSIONAL INFORMATION

Membership

Disclosures

REFERRAL

MAILING