Doctor Application

To be considered, applicants must be board-certified within their practicing specialty. It is also highly recommended that applicants list any recent history of publications in peer-reviewed medical journals. All applications will be vetted by the World Physicians Organization (WPO) Executive Board, the accrediting body for CONCIERGE KEY Health.

Upon submission, your credit card will be charged the annual membership fee, specified at the bottom of this application

* Mandatory - These fields are required.

First Name *

Last Name *

Specialty *

Practice Address *

Billing Address *
Same as Practice Address

Email *

Cell Phone *

National Provider ID Number *

Please list any medical societies you are a member of *

Please list any medical societies in which you sit on the board (or equivalent body) *

Please list your three most recent publications (if any), including dates:

Are you a consultant to industry? *

No Yes

If so, please disclose the companies you have been a consultant for:

Practice Manager Name *

Practice Manager Email *

Create Password *

Password Confirmation *

Credit Card Number *
The 16 digits on the front of your credit card

American Express

Discover

MasterCard

Visa

Zip Code
Your zip/postal code as it appears on your credit card statement

Upload CV

Authorization *

By initialing below, I authorize World Physicians Organization, LLC to store and charge this card for future purchases as agreed until I cancel this authorization. I understand I will be charged $2000 now, and if my application is approved, will be immediately charged an Annual Membership Fee. I understand that my Annual Membership term begins now and lasts one (1) year, or until December 31, 2018, whichever is later. I also understand that my credit card will be automatically charged on my next renewal date unless I provide a cancellation request at least FIVE (5) days prior to my next renewal date.

MEMBERSHIP TERMS *

By checking this box, I acknowledge that I have read and understood the World Physicians Organization Membership Terms.

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4040 MacArthur Blvd, Suite 310
Newport Beach, CA 92660

info@conciergekeyhealth.com

Doctor Application

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