Membership Application

Please fill out all applicable fields. Some fields will not apply to all applicants.

I hereby make application for membership in the London and District Academy of Medicine and, promise to observe its rules and promote its interests. I also agree that I will not practise or profess to practise any system of medicine not approved by the College of Physicians & Surgeons of Ontario (CPSO), and that I shall adhere to recognized scientific medical practice. I further agree to accept, uphold and be governed by the by-laws of the Society in force at the time of my becoming a member, and by an amendments or additions that may thereafter be made to them; and shall further agree to abide by and accept the rulings and decisions of the properly constituted authority of the Society. I hereby apply to join the London and District Academy of Medicine and agree to be bound by its constituting agreement.

* Required field

Please complete the form below

Name *
Name
Date of Graduation
Date of Graduation
Date of Registration in Ontario
Date of Registration in Ontario
Office/Mailing Address *
Office/Mailing Address
Office Phone *
Office Phone
Office Phone Unlisted
Office Phone Unlisted
Office Fax
Office Fax
Office Use Only
Home Address *
Home Address
Date of Birth
Date of Birth
Optional Information
Communication Preferences
Membership Purchase - After you submit your application to our office, please finalize your membership purchase by adding the appropriate level to your shopping cart and completing the check out process.
 

Looking to renew? Click below.

Membership Renewal
175.00
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Choose your level of membership below:

 
Practicing Physician
175.00
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Retired Physician
75.00
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Resident Physician
25.00
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