Become A Member Form

Public Physician Information

This information may be shared with the public.

First Name

Last Name

Designation

Email

Remember: This is a public email address, not your private email.

Profile Photo

Please upload a JPG or PNG image. Maximum file size: 5 MB.

Specialty 1

Specialty 2

Board Certifications

Public Practice Information

This information may be shared with the public.

Practice Name

Address

Office Phone

Office Fax

Website URL

Practice Manager

Practice Manager Email

Member to Member Physician Information

This information will be shared with members only.

Home Address

Cell Phone

Spouse's Name

Spouse's Email

I certify that the information provided in this application is accurate and that typing my name below serves as my electronic signature.

Signature

Date

Additional Information

If you have any questions, please contact Michelle Flaat, M.S. at michelle@flmedical.org or by calling (850) 784-2090.

Dues Payment

Annual Dues:

• Practicing Physician: $395

• Retired Physician: $100

• Physician Assistant: $195

Membership Type
Select Membership TypePracticing Physician - $395Retired Physician - $100Physician Assistant - $195

Payment Option
Select Payment OptionCardCheck

Card Payments: If you select Card, after submitting the membership application you will be redirected to the secure payment page for the membership type selected above. You will only be able to pay for that selected membership type.

Check Payments: If you select Check, your application will be submitted without redirecting to an online payment page. Make checks payable to Emerald Coast Medical Association.

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