Best Plastic Surgeon Sponsor Application

BoardCertifiedPlasticSurgeon.com
SPONSOR Application/Information Form
(attach separate sheets if necessary for all information)

Surgeon's name (as it appears on medical license):

Name as it should appear on listing:

Practice name:

Street address:

City/Town:

Listing city* or cities**:
*must be within 10 mi. of actual location
**in some cases, you may be listed in other nearby cities for no charge

Office hours:

Contact person:

Telephone:

Fax:

E-mail address:

Your current web site address: http://_____________________________________
(We also design a page on our site and also link to your personal page)
Click HERE to see one of our web pages.

Photo enclosed: Yes____ No_____

Take Photo from web site:Yes____ No_______
Indicate URL of web site where photo can be found

No photo desired: (check one)Yes_____ No ______

Curriculum Vitae: Add additional sheets if necessary

Undergraduate Information:

Medical School Information:

Medical License #(s), State(s)

Residency/Other:

Month/Year Board Certified by American Board of Plastic Surgery:

Sub-specialties:

Professional Societies:

Hospitals Privileges:

Professional Publications:

Procedures performed in order of frequency: ___________________________________

Personal information you want published: ______________________________________

(attach separate sheet if necessary)

List as: (cosmetic or reconstructive or both)
Specialty: (list up to 3)

Signature:___________________________________________________________________
SPONSOR PLEDGE*
By signing the above, I am stating that I am board-certified in plastic surgery by the American Board of Plastic Surgeons or the Royal College of Physicians and Surgeons of Canada, that my medical license in the state where I am practicing is current and has not been revoked (nor has it been revoked in any other state), and that I am not currently being investigated or disciplined, or being considered for discipline, by the Board of Medical Examiners of any state or country, nor has any Medical Board or comparable supervisory board deemed it necessary to bring disciplinary action against me in the past.
I further state that I will honestly answer any questons my patients ask me regarding malpractice settlements or judgments in the past or present.
I also promise to inform, immediately, the webmaster of www.BoardCertifiedPlasticSurgeon.com if the status of any of the above specifications have changed at any time during my listing period.
I understand that listing on BoardCertifiedPlasticSurgeon.com is at the sole discretion of the webmaster of BoardCertifiedPlasticSurgeon.com, I understand that my listing on BoardCertifiedPlasticSurgeon.com may be removed, and the remainder of the unused subscription fee, at a pro-rated monthly basis, up to 6 months, will be refunded to me. I agree with these terms and also agree not to take any legal action, and agree to forfeit the right to any and all legal action, against the webmaster or administrators of www.boardcertifiedplasticsurgeon.com for the removal of my listing.
Click to return to TOP of this plastic surgeon sponsor application.

* Due to the high-risk nature of a practicing plastic surgeon and the difficulty in checking such claims, and based on the suggestion of several professionals, we have removed the statement "I further state that I have never been successfully sued for medical malpractice" which had previously appeared on our pledge and have substituted: "I further state that I will honestly answer any questons my patients ask me regarding malpractice settlements or judgments in the past or present."

Please mail completed, signed application and fee to:
DVDEALS, PO BOX 442, Pittston, PA 18640.
E-mail us for current directory listing fee here (marion@boardcertifiedplasticsurgeon.com).
Please place LISTING FEE in the "subject" of the e-mail.

Terms
The terms of this agreement are for a limited time. The administrators of www.BoardCertifiedPlasticSurgeon.com reserve the right to change any and all terms and agreements without prior notice, and at our sole discretion. We also reserve the right to refuse to list any applicant, or to remove a listing, subject to a refund as set forth above, for any reason at any time, at our sole discretion. Please note that our administrators will check with applicable state Board of Medical Examiners/Board of Medicine to verify certain credentials. Thank you.