Membership Application Form

Membership Application Form

Please fill out the form carefully and choose your category to apply for membership in your Florida Pain Society. Ensure all required fields are completed accurately.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Practice Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Medical License Number*
Medical License Issuing Authority*
Medical/Nursing/Pharmacy etc. School Attended*
Year of Graduation*
Specialty/Field of Practice*
Medical Specialties*
Years of Practice Experience*
Current Practice Facility/Clinic Name
Practice Location (City, State)*
Practice Website or Profile Link
Professional Certifications and Licenses*
Additional Certifications or Special Training

My Products

Active Membership Open to MDs and DOsActive members are physicians who hold a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree and are licensed by at least one of the State of Florida’s Board of Medical Examiners or other State’s governing Board of Examiners. Active members will have full voting rights and be eligible to hold office until retirement from professional practice. If one qualifies for Active membership

$250.00

Affiliate Membership Affiliate members are non-physician (MD, DO) practitioners including but not limited to, DC, PharmD, PhD, PsyD, PA, NP, RN, LPN and other healthcare providers who are licensed by at least one of the State of Florida’s Practice Boards or other State’s governing Practice Board.

$150.00 Quantity

Become a Founding Member - add your support at an additional $250 - now through April 30, 2026For so long as you maintain your membership in good standing, you will be recognized as a founding member of the Florida Pain Society

$250.00 Quantity

Trainee MembershipTrainee members are individuals currently in an accredited healthcare profession training program including those executing fellowships. Trainees may stay in this membership category one additional year after the completion of their training program as they become licensed by his or her respective licensing board and transition into practice

$25.00 Quantity

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Agree to Membership Terms and Conditions*

I agree to abide by the membership guidelines and policies. For a copy of the Society Bylaws visit www.Floridapainsociety.org.
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