Please Tell us about your Large Urology Group!

Please fill out our online form below, or use our downloadable pdf form and fax us your large group information.
 
Membership Categories:

Requirements for Active Membership are as follows: a partnership, corporation, company or other business with ten (10) or more physician urologists that is engaged in the practice of urology and is located in the boundaries of the United States of America.

 

Requirements for Associate Membership are the same as Active Membership. Associate Members have less than ten (10) and more than five (5) physician urologists. At anytime Associate Members may upgrade their membership status in the Corporation to Active Membership when eligible.

 

Practice Information

Name of Corporation:* (the legal name of your large urology group practice)
       
Number of Urologists in your Large Urology Group Practice:*
Number of Offices in your Large Urology Group Practice:*
Potential expansion to include offices and urologists, expected (date)
 
*Is your practice multi-specialty? *Is your practice Academically affiliated?
       
Corporate Mailing Address: (the mailing address of your corporate headquarters)
Address 1:*   Address 2: City:*
       
State: Zip/Postal Code:* Country: Phone:*
       
Fax: Corporate Website Address:  
 
       

CORPORATE CONTACT (CHIEF OPERATING OFFICER, PRACTICE ADMINISTRATOR, CEO OR ITS EQUIVALENT)

First Name: Middle Name: Last Name: Degree(s):
       
Work Title: Phone: Email:  
 
     

Individual Urologist Information
First Name:* Middle Name: Last Name:* Degree(s):
       
Email:*      
     
       
Practice Mailing Address: (where you would like to receive mail or other correspondence)
Address 1:*   Address 2: City:*
       
State: Zip/Postal Code:* Country: Phone:*
       
Fax:      
     
       
   
If you would like an email confirmation of the information you have provided, please enter an email address below to send the confirmation to:
     
   
 
Copyright © 2008, Large Urology Group Practice Association. All rights reserved.