How to Apply
If you are a physician (MD or DO) interested in becoming a member of PTP, please fill out the online
"PTP Membership Application" below. You will be required to read and agree to the terms of the
"PTP Physician Member Services Agreement" as a part of the application process (click here if you wish to review this agreement now). If you prefer, you may request printed copy of the forms by calling our Physician Services office
at 1-800-768-6397. PTP adheres to the highest standards of privacy protection (click here to read our full policy). There are no initiation fees or annual dues for membership in PTP.

At the end of the application process, you will have the opportunity to choose a User Id and password. These will allow you temporary access to the site enabling you to immediately review your Personal Bio Page and sample PTP's suite of services. Upon approval of membership, you will be notified of your permanent password.

If you have any questions, please click here. to contact the appropriate PTP staff member. If you have not yet read the Terms of Use regarding your use of this site, please click here.
   
  Name (first, middle, last)    
  ("Licensed Physician")

  E-mail
Check if you want your email address displayed to the general public

  Medical Licenses  

  Medical Degree

  Medical School Attended

  Professional Specialtie(s)  
 
 
 

  Professional Interest(s)
 
 
 
 
 
 
 
 
 
 
 

  Office Clinic/Group
  Office Address
  Suite or #
  Office City
  Office State
  Office Zip Code
  Office Country
  Office Phone #
  Office Fax #
  Office Assistant Full Name
  Assistant Phone # or Extension
  Handicap Access yes no
  Office Hours
  Accepting New Patients yes no

  Languages Spoken
  ("Check all boxes that apply")
English Chinese French
German Italian Japanese
Korean Mandarian Russian
Spanish Other  

  Web Site1 Address

  Web Site2 Address

  Web Site3 Address

  Hospital Privileges/City/State
 
 

  Best Contact Method

  Board Certifications
 
 

  Society Affiliations
 
 
 
 
 

  Professional Team Affiliations
 
 

  Additional Team Affiliations
Team NameSportLevel
 
 
 

  Home Address

  Home Address

  Home City

  Home State

  Home Zip

  Home Country

  Home Phone

  Home Fax

  Date of Birth (m/d/year)    

I WISH TO BE INCLUDED IN THE FOLLOWING:
 
  PTP Physician directory - All Site Visitors yes no
  PTP Physician directory - Physician Members yes no
  Personalized Patient Education Site yes no
  PTP Information Updates yes no
  Media Referral Base yes no
  Research Referral Base yes no
  Educational Grant Referal Base yes no
 

  How did you learn about PTP?

  Referred by another PTP member?
  (Please identify)

Click here to read the "PTP Physician Member Services Agreement".

I have read and agreed to the
"PTP Physician Member Services Agreement."
  I agree

  User Name   NOTE: User name must be less than 50 chararcters.

  User Password   NOTE: password should be between 1-8 characters.
  Confirm Password   NOTE: passwords are NOT case sensitive.