FSDS General Membership Application

Why Join FSDS?
The Florida Society of Dermatologic Surgeons (FSDS) is the professional home for dermatologic surgeons across Florida. As a General Member, you’ll gain access to:
- Member-rate registration for the FSDS Annual Meeting and CME programs
- A statewide network of colleagues, mentors, and future leaders
- Opportunities to participate in committees, projects, and advocacy that shape our specialty
- Resources, education, and recognition that support your career and your practice
Joining the FSDS means more than membership, it means belonging to a community dedicated to advancing dermatologic surgery and patient care.
Applicant Information
Name*

First NameLast Name
Credentials*
Date of Birth*

MonthDayYear
Date
Gender*
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Office Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone (for internal use only)*
Please enter a valid phone number.Format: (000) 000-0000.
University / Hospital Affiliations*
DermatologistDermatopathologistPlastic SurgeonOther
Referred by (please put n/a if not relevant):*
1. Have you ever received an official censure or reprimand from a medical society?*
2. Are you now or have you ever been party to malpractice litigation?*
3. Have you ever been convicted of a crime*
4. Have you ever been subject to discipline by a medical or health care regulatory board or agency?*
5. Have you ever been subject to discipline by a hospital or healthcare organization?*
You're almost done!

Application submission is not considered final without payment of dues. Upon submitting this application, you will receive an email with a link to pay your dues, please be sure to complete this step in the process.

By hitting "submit" below, you are affirming that the information submitted is true and correct to the best of your knowledge. You hereby authorize the Florida Socieety of Dermatologic Surgeons to obtain verification of any of the information listed above.
Date*

MonthDayYear
Date
Signature*

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Applicant Information