Homeopathic Medical Society of the State of New York — Est. 1862
Please provide your contact information
Homeopathic Medical Society of the State of New York
Please add your professional details
Homeopathic Medical Society of the State of New York
Please share your other interests
Active Members- Complete all details. For students, residents and interns, skip to Agreements.
Active Members- Complete all details. For students, residents and interns, skip to Agreements.
Active Members- Complete all details. For students, residents and interns, skip to Agreements.
Active Members- Complete all details. For students, residents and interns, skip to Agreements.
To be completed by all applicants
Contact Information
Date:
Name:
Email address:
Repeat to confirm
Website:
Office Address
Street:
City:
State:
Zip:
Office Phone:
Home Address
Street:
City:
State:
Zip:
Home Phone:
Credentials and Practice
Degrees
New York Licenise #:
In what other states are you licensed to practice?
Type of Practice:
Interests
Homeopathic Interests:
Special Interests:
Membership Type
Class of Membership Desired and Annual Fees:
Birth and Citizenship (required for full membership)
Date and place of birth:
Citizenship:
If naturalized, give date and certificate number:
Education (required for full membership)
Undergraduate college or university:
Undergraduate degree and year:
Name of medical school and year graduated
Graduate Training (required for full membership)
Internship—Hospital, Type of service and dates of service
Residencies (list all)—Hospital, Type of service and dates of service:
Fellowships)—Hospital, Type of service and dates of service:
Additional Education (required for full membership)
Homeopathic Education:
Training in your specialty if not included in the above (where obtained and dates):
Certification (required for full membership)
Specialty board(s) and date(s) of certification:
If not board certified, are you eligible for board certification?
Appointments (required for full membership)
Hospital, courtesy:
Hospital, attending:
Teaching (give title and school with dates):
Professional Societies—If you have been or are a member, give name, dates and class of membership where appropriate (required for full membership)
Local medical society:
State or country medical society:
Professional societies (specialty or others):
Diplomate, American Board of:
American college of physicians:
American college of surgeons:
American college, associate of (name and date):
American college, fellow of (name and date):
Elected positions in medical societies:
Practice (required for full membership)
Exclusive of hospital and/or other training, for what period have you been engaged in practice?
If a specialist, how long have you practiced your speciality?
How long have you practiced in your present location?
Have you practiced elsewhere? If so, give locations and dates:
Type of Practice:
Other type of practice:
Other (required for full membership)
Have you ever been denied licensure in any state?
Explain denied licensure fully and give current status of license involved:
Have you ever had your license revoked?
Explain revoked licensure fully and give current status of license involved:
Are you currently or have you ever been investigated by the OPMC?
Explain OPMC investigation and give current status of license involved:
Are you engaged in any governmental position, business, trade or profession other than the practice of medicine?
Please specify your non-medical engagement:
Clubs of which you are a member other than professional:
Publications (Give title, journal, volume, year, page, authors.) Can also be uploaded as a separate document with this application.
References--List two. One may be an HMSSNY member. (required for full membership)
Reference 1: Name and complete address
Reference 1: In what capacity known:
Reference 1: How long known:
Reference 2: Name and complete address
Reference 2: In what capacity known:
Reference 2: How long known:
Additional Documents to submit with application
For Active, full memberships, please upload a copy of your NY State License
Max. size: 300.0 MB
For student/resident/intern memberships, please upload a copy of your student ID or letter from program director
Max. size: 300.0 MB
Additional upload materials to be considered with this application
Max. size: 300.0 MB