Become a Member

If you have any questions about this registration form, click here to send us an email.

  • Account Set-up Info

  • Enter the email address we should use to set up your account and where you would like to receive emails from the AFDMA. Please use a "permanent" email address (i.e not a student email or work email that might change). The email address entered here will *not* appear in the optional on-line directory unless you also enter it in the "Practice Email" field below. This gives you the option to receive AFDMA emails at an email address other than your practice email address.

  • Membership Type

    Student memberships are free until the student graduates, but annual renewal is required.
    You have selected a Group Membership. After a successful payment you will be able to invite up to %s additional members.

    Add Your Group Details

  • Student Members Only: Please enter the school you are currently attending
  • Student Members Only: Please enter your expected graduation date (doesn't have to be the exact day) from Medical School.
    Check this box to signify that you are a member in good standing with your national organization. Documentation may be requested.
    Regular Members Only: Select 'Yes" only if you wish your public info to be included in the Online Membership Directory. This setting is ignored for Student Members.

  • Contact Info

    With the exception of your name, info you enter here is used only by the AFDMA to communicate with you about your membership. Name info is published in the "Find a Practitioner" directory that all non-Student members may *optionally* opt-in choose to be included in.
  • Required phone number format: (###) ###-####
    Best number to reach you at should we need to contact you for any reason. This number will *not* be published in the optional Online Membership Directory If you would like this number to be listed there, you will also need to enter it into the "Practice Phone" field below..
  • Drop-down lists US states in alphabetical order followed by Canadian provinces and territories in alphabetical order.

  • Tell Us About Yourself

    All info from this point on will be considered public info and will be published in the online "Find a Practitioner" directory unless you opted-out above. With the exception of Credentials, all fields are optional, so fill-in only those fields that you want included in your listing.
  • Upload We suggest uploading a "headshot" picture of yourself. You will have an opportunity to upload up to 6 images about your practice below. If you do not upload a profile picture, the AFDMA logo will be used as a placeholder.

  • Tell Us About Your Practice

  • Required phone number format: (###) ###-####
  • Required phone number format: (###) ###-####
  • Published Email for your practice. If same as above, enter again.
  • Drop-down lists US states in alphabetical order followed by Canadian provinces and territories in alphabetical order.
  • To place your map pin, enter the address where you would like the pin placed, then zoom in to your location and and verify it is correct.

  • Tell Us More About Yourself

  • If not a DO or MD, please provide school where you achieved your healthcare degree and year completed.
  • ×The maximum number of images has been reached.
    • ×+
    • Upload Upload an image to display on your profile. You may upload up to 6 images. For additional images, click the + sign at the lower right of this box. Allowed file types are: .gif, .jpg, .png
    • ×+
    • Upload Upload an image to display on your profile. You may upload up to 6 images. For additional images, click the + sign at the lower right of this box. Allowed file types are: .gif, .jpg, .png

  • About Payment Methods

    If you select PayPal, you will be taken to PayPal.com to complete the transaction once you press 'Register.'

    • Payment Details

    • Billing Details

    • If entered, this will appear on the invoice, replacing the First and Last Name.