Physician Enrollment Form - National Organization of American Physicians™

TOLL FREE PHONE 1-800-582-0095

U.S. PHYSICIAN ENROLLMENT

PHYSICIANS WHO WOULD LIKE TO RECEIVE FREE NATIONAL MEDICAL CLINIC, INC. PATIENT REFERRALS AND TREATMENT PROTOCOLS ARE INVITED TO COMPLETE THE REGISTRATION FORM BELOW

NATIONAL ORGANIZATION OF AMERICAN PHYSICIANS™

Please fax a copy of (1) your state medical license(s) and
(2) DEA license to FAX number 1-561-443-7736 or e-mail them to nationalmedicalclinic@earthlink.net after completing this online registration form. Thank you.

Physician's first name

Physician's last name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Business Phone

FAX

Emergency Mobile Phone (212-555-2121)

E-mail

List All States in Which You Have a Medical License by State of Issuance

Medical License Number:

Federal DEA Number:

Board Certifications:

Medical School:

Testosterone Hormone Replacement Therapy for Hypogonadotropic Men with Low Testosterone

HCG Therapy to Increase Natural Testosterone Production in Men

Male HCG, FSH and LH Medical Infertility Treatment to Induce Spermatogenesis in Hypogonadotropic Men

Medical HCG Weight Loss Treatment Combined with the South Beach Diet® for Men and Women

Medical Hair Growth Restoration through the Administration of Finasteride/minoxidil Cream for Men with Male Pattern Baldness

Sermorelin Acetate (foermerly Geref™Growth Hormone-Releasing Hormone Therapy to increase Pituitary Production of Human Growth Hormone (hGh) to increase bone density, enhance immune system, strengthen the heart (and other bodily organs) and accelerate the recovery from surgery or bodily injuriesc

Viagra™, Levitra™ or Cialis™ Medical Erectile Dysfunction Treatment for Men

Reproductive Endocrinology Physician Services

Endocrinology Physician Services

Urology Physician Services

Weight Loss Medicine

Fertility Medicine

Internal Medicine Physician Services

General Practice Physician Services

Family Practice Physician Services

Professional Medical Malpractice Insurer:

Policy Number:

Amount of Coverage:

Medical Specialties

Medical Residencies - Locations and Dates:

Medical Degrees Received:

Medical Fellowships Completed and Locations:

Describe any disciplinary hearings conducted, license suspension, license
revocations, or any disciplinary investigations or actions with respect to yourself by any
reviewing or licensing medical board or governmental authority during the past 10 years.

If you have any questions, please call National Medical Clinic, Inc. at 1-800-582-0095