MD or DO Membership Application

MD/DO Membership Application

Dear Doctor, We look forward to your membership! By completing the application below, and submitting the minimum $350 membership dues, you are certifying that you are a Medical Doctor or Doctor of Osteopathic Medicine and that you are opposed to mandatory vaccination laws. As such, you agree to keep matters discussed in our private web forum strictly confidential. It may take over a one week for you to be added to the forum, depending on how long it takes us to contact your professional reference.

Thank you!
Physicians for Informed Consent

*Contributors of $10,000 or more annually are invited to the annual leadership dinner and other special events.
**Contributions are tax-deductible as allowed by law. 

Honoree Information
 
Select an option to reveal honoree information fields.
Physician Profile
Your name will remain confidential. We will not be making our membership public.
This information will be used to verify your license.
Physician friend? Newsletter? Networking?
Please let us know if you would like to volunteer as a contact person or mentor for physicians in your area.
 
 
Please list the name and phone number of a colleague we may contact.
Credit Card Information
*
*
*
 
Billing Name and Address
*
*
*
*
*
*
*