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BoardCertifiedPlasticSurgeon.com (sm)
PO BOX 442, Pittston PA 18640 Directory Application Page 1 of 2 - MUST be acompanied by Page 2 (signed and dated DIRECTORY PLEDGE) Directory Fee*: Please email Marion@BoardCertifiedPlasticSurgeon.com *Fee is per city / surgeon and we reserve the right to change this fee at any time. Surgeons must qualify. See DIRECTORY PLEDGE Multi-city listings may be discounted (we can create a new city directory ifn one does not already exist) but towns should be within reasonable driving distance of office. Limit per city is five Directory Surgeons: first come, first served (if qualified). All surgeons (new listing and renewing): must qualify by taking our Directory Pledge yearly. Renewals: see renewal letter for discount information. Indicate changes on Directory Application. No changes to listing? Simply list name, sign Pledge, mail w/payment. Payment to BoardCertifiedPlasticSurgeon.com by check, cashier's check or money order only! | ||||||||||||||||||||||||||||||||||||||||||
| Plastic Surgeon's name (as it appears on medical license): | ||||||||||||||||||||||||||||||||||||||||||
| Gender: male / female (circle one) State and MD Licence #: | ||||||||||||||||||||||||||||||||||||||||||
| List past and/or present licensure in other states or countries: | ||||||||||||||||||||||||||||||||||||||||||
| Name as it should appear on listing: | ||||||||||||||||||||||||||||||||||||||||||
| Practice name (if different than above): | ||||||||||||||||||||||||||||||||||||||||||
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Practice street address:
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| Practice City/Town/Zip Code: | ||||||||||||||||||||||||||||||||||||||||||
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*Listing city:
* Some surgeons request to be listed in a city other than or in addition to their actual practice city. We can create a City Directory for any city, town or borough. | ||||||||||||||||||||||||||||||||||||||||||
| Specialty (check one or both): Cosmetic______ Reconstructive_______ | ||||||||||||||||||||||||||||||||||||||||||
Option: List total of 10 - 12 procedures frequently performed by you:
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| List Office Hours (if desired): | ||||||||||||||||||||||||||||||||||||||||||
| Contact person: ___________________________ E-Mail:_________________________________ Publish? Yes or No | ||||||||||||||||||||||||||||||||||||||||||
| Office Telephone:___________________________ Fax#_______________________________Publish Fax?_____ | ||||||||||||||||||||||||||||||||||||||||||
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Your current web site address: http://www.____________________________________
Web address will be listed but NOT be linked. We currently link only SPONSORS to their personal practice sites. | ||||||||||||||||||||||||||||||||||||||||||
| Month/Year Board Certified by American Board of Plastic Surgery or RCPSC: | ||||||||||||||||||||||||||||||||||||||||||
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Please mail completed, signed application and fee - $99/3months/ $150.00(6 months)/ $250.00 (1 year)- payable to BoardCertifiedPlasticSurgeon.com:
BoardCertifiedPlasticSurgeon.com, PO BOX 442, Pittston, PA 18640. 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 may check with applicable state Board of Medical Examiners/Board of Medicine to verify certain credentials. Thank you.
Copyright 2008 - 2011 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved | ||||||||||||||||||||||||||||||||||||||||||