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Membership Application
*
1.
First Name
(Required.)
2.
Middle Name
*
3.
Last Name
(Required.)
*
4.
Credentials (MD, DO, PhD, etc)
(Required.)
5.
Date of Birth
*
6.
Specialty
(Required.)
Anesthesiology
Neurology
Neurosurgery
Orthopedic Surgery
Physical Medicine and Rehabilitation
Radiology
Not Listed, Please Specify, or Medical Student
IPSIS asks the following questions on gender and race to monitor progress on our commitment to promote structural changes that foster diversity, equity, and inclusion in interventional pain medicine.
7.
Type of Practice
Solo Private Practice
Owner/Equity Owner of Single-Specialty Group Practice
Owner/Equity Owner of Multi-Specialty Group Practice
Employee of a Group Physician Practice
Employee of Hospital/Healthcare System
Academic Institution
Other (please specify)
8.
For Group Practice Physicians: What is the Approximate Size of Your Group?
2-10
11-20
21-50
51+
N/A
9.
Gender
Female (including transgender women)
Male (including transgender men)
Prefer not to say
Prefer to self describe as (non-binary, gender-fluid, agender, please specify)
10.
Race
Select all that apply.
African
African American/Black
Asian American
East Asian (Including Chinese, Japanese, Korean, Mongolian, Tibetan, and Taiwanese)
Hispanic/Latinx
Indigenous American/First Nations (Including Native American, American Indian, Alaskan Native, Pacific Islander, and Native Hawaiian)
Middle Eastern
South Asian (Including Bangladesh, Bhutanese, Indian, Nepali, Pakistani, and Sri Lankan)
Southeast Asian (Including Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Thai, and Vietnamese)
White
Not Listed, Please Specify
*
11.
Preferred Primary email
(Required.)
Personal
Program
*
12.
Preferred Mailing Address
(Required.)
Personal
Program
13.
Personal email
14.
Personal Phone
*
15.
By checking the opt-in box below, you agree to receive text messages from International Pain and Spine Intervention Society. Click opt-out if you would like to unsubscribe from receiving text messages.
(Required.)
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16.
Personal Address
17.
Practice/Program email
18.
Practice/Program Phone
19.
Practice/Program Address
