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New Member Application

Please complete all fields to ensure your application is processed smoothly. If a field is not applicable, type NA. Payment is due when application is submitted.

First Name *

Middle Initial

Last Name *

Suffix

Professional Designation *

NPI Number *

Are You Board Certified? * Yes No

Other Names Used

Birth Date *

Gender *

Marital Status *

Spouse Name (if applicable)

Other Languages

Contact Information

Home Address *

Home City *

Home State *

Home Zip *

Work Address

Work City

Work State

Work Zip

Mobile Phone *

Email (Used to Login) *

Active Military? Yes No

If yes, what branch?

Dates in Service

How did you hear about OCMS/OSMA? *

Practice Information

Practice Name *

Office Phone Number *

Office Address *

Office City *

Office State *

Office Zip *

Office Website *

Office Manager Name *

Office Manager Phone *

Office Manager Email *

Practice Type *

Would you like us to contact your office manager with billing and/or membership questions? * Yes No

Professional Information

Medical Practice Start Date *

Primary Specialty *

Secondary Specialty *

Medical School Name *

Medical School Graduation Year *

Residency Name/Location *

Year Residency Completed *

Internship Name/Location *

Year Internship Completed *

What date did you begin practice after your training was complete? *

Submit Application

Password *

Communication Preferences

Select all that apply.

Your Photo

We use your photo to announce your membership in our bi-monthly publication.

Email and password provided will be used for website login. Please read terms below. By selecting this box, I agree to the authorization & agreement terms as listed below.

I understand that by providing my contact information, I consent to receive communications from OCMS and OSMA. (email addresses of AMA members will be provided to the AMA). I, the undersigned applicant, hereby certify that I understand fully that membership in the Oklahoma County Medical Society and Oklahoma State Medical Association is a privilege. If this application is approved by the OCMS Board of Directors and I am accorded the privilege of membership, I hereby agree to abide by the provisions of the OCMS and OSMA Constitution and Bylaws and to practice in accordance with the established usages of the profession, and endorse the Principles of Medical Ethics set forth by the American Medical Association.