Dermatologic Society of Greater New York

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The Dermatologic Society of Greater New York has a proud and long history as one of the premier dermatologic societies in the country. To apply for membership, please fill out the new member application form below. The annual membership fee of $300.00 will be requested at the end of the application process. After activation you will be able to edit your profile at any time.

Information received will be validated by The Dermatologic Society of Greater New York. The Dermatologic Society of Greater New York reserves the right to remove false, misleading or inappropriate information and edit copy to conform to the standard profile format.

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First Name

Middle Initial

Last Name

Title(s) (Separate multiple with comma ",")

Gender

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Date of Birth

Password

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Primary Practice Name

Street Address 1

City 1

State 1

Zip Code 1 (5 digits)

Telephone 1 (area code first)

Fax 1 (area code first)

Email 1

Show Email 1 on website

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Website 1

Office Hours 1

	From	To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Secondary Practice Name

Street Address 2

City 2

State 2

Zip Code 2 (5 digits)

Telephone 2 (area code first)

Fax 2 (area code first)

Email 2

Show Email 2 on website

Yes No

Website 2

Office Hours 2

	From	To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

SPECIALIZED TRAINING

	Acne		Birthmarks
	Botox Injections		Chemical Peels
	Chronic Ulcers		Collagen Injections
	Cosmetic Skin Procedures		Cutaneous T-Cell Lymphoma
	Dermatologic Surgery		Dermatopathology
	Eczema, Atopic and Contact Dermatitis		Environmental/Occupational Skin Diseases
	General Dermatology		Geriatric Dermatology
	Hair and Nail Disorders		Hair Transplantation
	Itching/Urticaria/Allergic Skin Disease		Keloids and Scars
	Laser Hair Removal		Laser Resurfacing
	Laser Surgery		Liposuction
	Mohs Micrographic Surgery		Mole Removal
	Mycosis Fungoides		Pediatric Dermatology
	Pemphigus and Blistering Disorders		Photomedicine/Phototherapy (light therapy)
	Pigmentary Disorders		Psoriasis
	Rheumatologic Diseases		Sexually Transmitted Diseases
	Skin Cancer/Melanoma/Dysplastic Nevi		Skin Rejuvenation Therapy
	Skin Resurfacing		Spider and Varicose Veins
	Warts

Medical License No.

State

Date

Continuing Med. Educ. No.

Board Eligibility / Board Certificate Date

AAD Member Number

HOSPITAL AFFILIATIONS

Institution 1

Institution 2

Institution 3

Institution 4

Medical School and Year of Graduation

RESIDENCY TRAINING

Residency 1

Residency 2

Residency 3

FELLOWSHIP TRAINING

Fellowship 1

Fellowship 2

Fellowship 3

Professional Biography
(limit to 1000 words)

Health Care Participation
(enter one per line)

Medicare/Medicaid Participation

Accept Medicare Accept Medicaid

CME Recognition Award Status

KEY PROFESSIONAL ACHIEVEMENTS AND AWARDS

Achievement 1

Achievement 2

Achievement 3

Achievement 4

Achievement 5

Achievement 6

Achievement 7

Achievement 8

Achievement 9

Achievement 10

LANGUAGES other than English

	Arabic		Armenian
	Chinese		French
	German		Greek
	Hebrew		Hungarian
	Italian		Japanese
	Korean		Polish
	Portuguese		Romanian
	Russian		Spanish
	Thai		Yiddish

Upon submitting your application you will be taken to our payment processing partner, Pay Pal, for payment of our annual membership fee of $300.00

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