Become a Member If you have any questions about this registration form, click here to send us an email. Account Set-up Info Username* Password* Repeat Password* E-mail* Enter the email address we should use to set up your account and where you would like to receive emails from the AFDMA. This email address will *not* appear in the optional on-line directory unless you also enter in the "Practice Email" field below.Membership TypeInstitutional Membership - $1,000 for 6 members / 1 YearRegular Membership - $200 / 1 YearIntern, Resident and Fellow Membership - $50 / 1 YearStudent Membership - Free / 1 YearAutomatically renew subscription You have selected a Group Membership. After a successful payment you will be able to invite up to %s additional members. Group Name * Group Description Expected Graduation Date? Student Members Only: Please enter your expected graduation date (doesn't have to be the exact day) from Medical School. I am a member in good standing with my national organizationYesCheck this box to signify that you are a member in good standing with your national organization. Documentation may be requested. Publish Public Info?YesNoRegular 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 First Name* Last Name* Nickname Best Phone Number 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..Tell Us About YourselfAll 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.Profile PictureUpload 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. Credentials* UndesignatedD.O.M.D.D.O. Medical StudentM.D. Medical StudentAPATCDCDDSDMDDPMNDNPOTPA-CPTPTASI (Certified in Structural Integration) Job Title Department Tell Us About Your Practice Practice Name Practice StatusPrivate PracticeFacultyHospitalResidency/FellowInternshipActive MilitaryGovernment/Retired MilitaryOther Other Practice Status Practice Phone Required phone number format: (###) ###-#### Fax Required phone number format: (###) ###-#### Practice Email Published Email for your practice. If same as above, enter again. Website Facebook Page LinkedIn Profile Address 1 Address 2 Address 3 City State/Province OtherALAKAZARCACOCTDED.C.FLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYABBCMBNBNLNSNTNUONPEQCSKYT Drop-down lists US states in alphabetical order followed by Canadian provinces and territories in alphabetical order. ZIP/Postal Code Province Country Select a CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the CongoReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe MapTo 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.×The maximum number of images has been reached.×+ImageUpload 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×+ImageUpload 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, .pngTell Us More About Yourself School & Graduation Date Non-DO/MD Healthcare School If not a DO or MD, please provide school where you achieved your healthcare degree and year completed. Internship & Year Completed Residency & Year Completed Area of Practice Certifications Other Professional Degrees Biographical Info Send these credentials via email.