SLiiM Membership Form

Membership Form
For Licensed Medical Professionals Only!
Name*

First NameLast Name
Practitioner Type*
If Other then enter in next box
Other Practitioner Type
Practice Name*
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Practice Email*
example@example.com
Practice Description - This is where you give patients an opportunity to learn about you and your practice. This should ideally be in paragraph form (see the SLiiM directory for examples).*
Practice Website Address*
Example: www.sliim.org
Do you accept most major insurances?*

YESNO
Type of Insurance?*

In-NetworkOut-of-Network
List your specialty categories for the Directory (may list up to 3)*

AddictionAcupunctureChild Life SpecialistCardiologyChiropracticChronic FatigueChronic PainDentistryFamily Medicine/Internal MedicineFunctional/Integrative MedicineGastroenterologyGut HealthHIV SupportIntegrative/ Holistic OncologyInterventional Pain Management-NeuromodulationLifestyle CoachingMental HealthNutritionOsteopathic MedicineOzone TherapiesPediatricsPharmacyPhysical Medicine & RehabilitationRegenerative MedicineWomen's Health
If you do not see the category you would like to be listed under, please enter it here and we will consider your entry.
Upload a photo of yourself for our Directory (head shot only)*
You will receive an invoice from SLiiM for membership payment - Annual Membership is $310.00

You will not be added to the directory until payment has been received
Membership will be automatically renewed annually. However, we will notify you by e-mail before charging your saved credit card.
Enter the best e-mail to notify you about events. This is for office use only.
Personal Email*
(For Office Use Only)
Mobile Phone Number*
(For Office Use only)
Should be Empty: