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Terms:

$400 / Year

First Name:* First Name Required

Last Name:* Last Name Required

Gender:* Gender is Required

Male Female

Organization:* Organization is Required

Office Phone:* Office Phone is Required

Mobile Phone:* Mobile Phone is Required

Org. Street :* Org. Street is Required

Org. City, State, Zip:* Org. City, State, Zip is Required

Website:* Website is Required

Email Contact :* Email Contact is Required

Practice Specialization :* Practice Specialization is Required

Physical Medicine & Rehabilitation Family Medicine Sports Medicine Interventional Pain Orthopedics Podiatry Other

Degree(s):* Degree(s) is Required

MD DO DPM PhD Fellow Other

Principal Practice Setting:* Principal Practice Setting is Required

Single Specialty Group Hospital Academic Hospital Community Research Military Multispecialty Group Solo Provider

Organization Size:* Organization Size is Required

Physician's State Lic#:* Physician's State Lic# is Required

NPI# (required to list you on Health Grades through IOF membership):* NPI# (required to list you on Health Grades through IOF membership) is Required

How did you hear about IOF?:* How did you hear about IOF? is Required

I hereby consent to the release by any hospital, educational institution, governmental agency, physician, professional society, or other person posessing or requiring the same whether or not listed above, of any and all information in any way pertaining to my personal character, training, experience, or professional competence. I hereby release from any liability the Interventional Orthobiologics Foundation and any and all individuals for their acts performed in good faith in connection with evaluating my application and my credentials and qualifications. I hereby certify that all information recorded on this application and any attached documents are accurate and support my qualifications for membership in the Interventional Orthobiologics Foundation for which I now apply. I hereby agree that Interventional Orthobiologics Foundation may verify any of the above data. I hereby understand that my payment today is non-refundable, to cover processing fees and immediate initiation of membership. Note: This membership renews automatically at the end of one year for an additional year, every year, unless terminated by member or IOF. Member may cancel at anytime.*

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