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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

 
 
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