New Member Registration

OPMS Online Membership Application

PERSONAL INFORMATION

Last Name (as shown on medical license)*

First Name*

Birthplace

Degree

Date of Birth

Gender

Home Address

City

State

Zip

Phone

Marital Status

Spouse's Name

Personal Email*

PROFESSIONAL PRACTICE INFORMATION
(IF APPLICABLE)

Louisiana License Number

Other State Licenses

ME # (if known-optional)

Preferred Mailing Address

Office

Home

Practice Name or Group (If Applicable)

Primary Specialty

Subspecialty

Primary Practice Address

City

State

Zip

Telephone

Fax

Email Address

Website

EDUCATIONAL INFORMATION

UNDERGRADUATE COLLEGE

Degree

Address, City, State, Zip

From

MEDICAL SCHOOL

Address, City, State, Zip

From

INTERNSHIP (Hospital)

Specialty

Address, City, State, Zip

From

RESICENCY (Hospital)

Specialty

Address, City, State, Zip

FELLOWSHIP

Specialty

Address, City, State, Zip

From

MEMBERSHIP APPLICATION AND QUALIFICATION QUESTIONS

Members abide by the bylaws of the Orleans Parish Medical Society. To assist us in upholding these standards, please provide answers to the following questions, sign and date.
If you answer yes to any of these questions, please email full information after submitting your online application.

Have you ever been convicted of fraud or a felony?

Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any imposed sanctions or conditions.

Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?

I am aware that information submitted in this application will be verified. I hereby authorize other organizations having information relating to this application, including governmental and regulatory entities, to release any and all such information. I understand that any false or misleading statement made on my application may be grounds for denial of membership or probation or censure by, or suspension or expulsion from the medical society.
The foregoing information is true and complete.

Digital Signature

Please type your full name in the space below. This serves as your digital signature.

Questions or Comments

Membership Type and Dues

Select Dues to be Paid*

Active Member... $250/year

Part-time Member... $150/year

Students/Residents... $0.00

Total Amount

Payment method *

I will mail a check
I will Pay Online with a Credit or Debit Card

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*

OPMS Online Membership Application

PERSONAL INFORMATION

PROFESSIONAL PRACTICE INFORMATION(IF APPLICABLE)

EDUCATIONAL INFORMATION

MEMBERSHIP APPLICATION AND QUALIFICATION QUESTIONS

Membership Type and Dues

PROFESSIONAL PRACTICE INFORMATION
(IF APPLICABLE)