LUGPA

Membership Application

PLEASE TELL US ABOUT YOUR UROLOGY GROUP PRACTICE

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?

Imaging:

Radiation:


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: 7581

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