Membership Application


Requirements for Membership are as follows: a partnership, corporation, company, or other business that is engaged in the independent practice of urology and is located in the boundaries of the United States of America.

There are two membership categories:

  1. Standard members are independent urology groups of five (5) or more urologists and/or urogynecologists
  2. Associate Members are independent urology groups of less than five (5) urologists and/or urogynecologists

Submitter Information

  • FullName:*
  • Phone:*
  • Email:*

Practice Information

  • Name of Corporation:* (the legal name of your group practice)
  • Address 1:*
  • Address 2:
  • Address 3:
  • City:*
  • State/Province:
  • Zip/Postal Code:*
  • Country:
  • Phone:*
  • Fax:
  • Corporate Website Address:

  • Current Number of Urologists?*
  • Current Number of Urogynecologists?*
  • Current Number of Offices in your Group?*

  • Potential Expansion to Include

  • Number of Additional Offices?
  • Number of Additional Urologists?
  • Number of Additional Urogynecologists?
  • Expected Date of Completion?(eg. MM/dd/yyyy)
  • Is your Practice Multispecialty?
  • Is your Practice Academically Affiliated?
  • Number of Physician Assistants?
  • Number of Nurse Practitioners?

Which of the following services does your practice provide?



Practice Administrator, Urologist(s), Urogynecologist(s), COO, CEO

Please use the Add Individual tool below to list all Urologists, Urogynecologists, COOs, CEOs and Practice Administrators.*

*Membership will not be approved until a full listing of all urologists and urogynecologists is collected.

Add Individual

  • Enter Security Code: 3205

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