MEDEON Members-Only Physician Organization

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Confidentiality statement – Medeon adheres to strict online privacy standards and is committed to protecting the privacy of its online members.

Medeon will contact you via email once your registration has been accepted and to communicate with you about opportunities and program updates

About You

Name:

First * REQUIRED

Last * REQUIRED

Suffix

Degree Abbreviations:

Specialty:

if other,

Date of Birth:
mm/dd/yyyy

Gender:

Male
Female

Home Address:

City:

State:
* REQUIRED

Zip Code:

Email Address:
* REQUIRED

Spouse's Name:

Telephone - Home: ( )

Telephone - Cell: ( )

Best time to be reached:

How should we contact you?:

Desired Password:
* REQUIRED

Confirm Password:
* REQUIRED

About Your Practice
Name of Practice:
Office Manager/Contact:
Office Manager Email Address:
Address:
City:	State: * REQUIRED	Zip Code:
Telephone - Office: ( ) * REQUIRED
Fax - Office: ( )
Web Site:

Practice Type Number: (Select Only One Number)

Status In Practice:

1 - Owner
2 - Consultant
2 - Employee
3 - Partner

Practice Sites:

Assisted Living College/University

Combination Home Care

Hospital Nursing Home

Office OTHER

if other or college,

Number of Patients:

Est. Prescriptions per Month:

UPIN Number:

License Numbers (One per line):

States In Which You Are Licensed To Practice:

ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY

LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO

OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WASHINGTON, DC
WEST VIRGINIA
WISCONSIN
WYOMING

Payment Information

Membership Type:
* REQUIRED

Associate ($75/year)
PAHCOM Member ($20/year)

Payment Code:

A Payment Code Will Work In Lieu Of A Credit Card Number

Promotion Code:

Your Credit Card Will Still Be Required

Credit Card Type:

Expiration Date: /

Number: No spaces or dashes please

Name on Card:

Billing First Name:

Billing Last Name:

Billing Address1:

Billing Address2:

Billing City:

Billing State:

Billing Zip Code:

Referral Code:
If you were referred to us by one of your colleagues, please enter their code here.

100% Satisfaction Guarantee Or Your Money Back
If for any reason you are not fully satisfied while a Medeon member, we will issue you an immediate and no-hassle refund of your annual membership dues!
That's It! No Fine Print.
We want you to tell your colleagues about Medeon!
Our business depends on referrals and satisfied customers.


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