Home     Privacy Statement    


An Organization of Healthcare Professionals Dedicated to Excellence in Spinecare


Membership Application


First Name:
Last Name:
Middle Initial:
Office Addr:
Suite, etc:
Province
City:
State:
Country:
Zip Code:

Contact Person:
Office Phone:
Home Phone:
Fax Number:
Practice Name:
Title:
Web Site http://
How Did You hear about The AASP:
Method of Contact:
Email:

Please check the appropriate membership category

  Member ( $250 per membership year )

This level of membership is for physicians (MD, DC, DO) whose practice/interest includes patients with spinal disorders

Designate your degree and your specialty below

Degree: BS DC DO MBA MD MPH NMD PhD
Specialty: Neurosurgeon Chiropractic Physician Orthopedic Surgeon Radiologist Rheumatologist Physiatrist Osteopath Pain Management Anesthesiologist Chiropractor Naturopathic

 Affiliate Member ( $150 per membership year )

This level of membership is for allied healthcare professionals involved in spinecare and/or spine research. This includes physical therapists, massage therapists, exercise physiologists, nurse practitioners, nurses, physician's assistants, diagnostic technicians, surgical technicians, exercise instructors and personal trainers.

Designate your degree and your specialty below

Degree: BS MS PhD MT RN PA CA RT AS DPT
Specialty: Radiology Technician Exercise Physiologist Massage Therapist Nurse Practitioner Physicians Assistant Surgical Technician Chiropractic Assistant Exercise Instructor Personal Trainer Nurse
 Candidate Member ( $35 per membership year )

This level of membership is for residents, fellows and students who have an interest in spinecare.

Status: Student Resident Fellow

PLEASE NOTE:
Membership will automatically renew one calender year from the date of membership acceptance unless the AASP is specifically notified in writing by the member 30 days prior to their renewal date. Please address all correspondence to the AASP Office of Member Services.

Card Number:
Name on Card:
Expiration Date: /
Card Type:
Billing Address:
City:
State/Province:
Zip:
Country:

I hereby make voluntary application to the American Academy of Spine Physicians (AASP). I understand and agree that in making application to, and/or being accepted as a member of the AASP, that I am a licensed healthcare professional and that my professional practice as such includes the evaluation and care of patients with spinal disorders.

I further agree that I will honor and comply with all local, state and federal laws and regulations which apply to me as a person and professional, and that I will conduct myself in a manner consistent with the highest level of professional ethics and in accordance with the ethical standards of the AASP as outlined in the AASP Documentation Library.

I affirm that the information I have provided to the AASP is true and accurate. I agree to function within the limits of my training, competence and professional license or certificate. I further understand and agree that the AASP and its affiliates assume no responsibility for any of my activities or actions. Membership dues are subject to change with prior notification.


ACCEPT DECLINE