Physicians, Dentists, Optometrists, Podiatrists, and Veterinarians
Membership Options
Founding Member - $1000+
Membership tier for those wishing and able to make a significant contribution to the organization,
fueling our mission and vision.
Sustaining Member - $500-999
Membership tier for those wishing and able to offer additional financial support to the organization,
fueling our mission and vision.
BMDF Member - $250
Full membership in the organization, with all membership privileges.
1st Year in Practice - $150
Full membership in the organization, with all membership privileges.
Retired
- $100
Full membership in the organization, with all membership privileges.
Dues are set by the BMDF Board of Directors. Dues are for 12 months from the date of joining.
Selected Dues (see options above)
Amount
Type of Donation
Recurring Dues
One Time Dues
Frequency
Annual
Contact Information
First Name
Last Name
Preferred Name
Address
Address 2
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
Country
United States of America
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote Divoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Lao
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts
Saint Lucia
Saint Martin
Saint Pierre
Saint Vincent
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Cell Phone
International Phone
Email (please do not use .edu addresses)
Additional Information
College
Professional/Graduate Institution
Professional/Graduation Institution Graduation Year
Residency and/or Fellowship Institution
Residency Completion Year
Professional Degree
Medical Specialty
Aerospace Medicine
Allergy and Immunology
Anesthesiology
Cardiology
Colon and Rectal Surgery
Dentistry - General
Dentistry - Endodontics
Dentistry - Orthodontics
Dentistry - Pediatrics
Dentistry - Periodontics
Dental - Prosthodontics
Dermatology
Emergency Medicine
Endocrinology
Family Medicine
Gastroenterology
Genetics
Hematology
Infectious Disease
Internal Medicine
Internal Medicine/Pediatrics (Med/Peds)
Nephrology
Neurology
Neurology - Child
Neurosurgery
Nuclear Medicine
Obstetrics and Gynecology
Occupational Medicine
Oncology
Ophthalmology
Optometry
Oral and Maxillofacial Surgery
Orthopedic Surgery
Other
Otolaryngology - Head and Neck Surgery
Pathology
Pediatrics
Pediatric Cardiology
Pediatric Critical Care
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Infections Disease
Pediatric Nephrology
Pediatric Pulmonology
Pediatric Rheumatology
Pediatric Surgery
Physical Medicine and Rehabilitation
Plastic Surgery
Podiatry
Psychiatry
Public Health
Pulmonary/Critical Care
Radiation Oncology
Radiology - Diagnostic
Radiology - Interventional
Rheumatology
Surgery - General
Surgery - Vascular
Thoracic and Cardiac Surgery
Urology
Other specialty or sub-specialty
Place of Worship (please include name, city, state, country)
Area of Ministry Interest
Africa
Australia/New Zealand
Asia
Europe
Middle East
North America
South America
Other
Area of Ministry Interest 2
Africa
Australia/New Zealand
Asia
Europe
Middle East
North America
No Preference
Other
South America
Other areas of interest
What other information would you like BMDF to know about you?
Help Us Cover Costs
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Payment Information
Payment Options
New Credit Card
New Bank Account
Credit Card Information
Card Holder Name
Visa
MasterCard
Discover
Card Account Number
Expiration Date
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
24
25
26
27
28
29
30
31
32
33
34
Security Code
Billing Address
Same As Above
Address
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
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