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About Us
Current Members
Membership
Events
Patient Resources
Gallery
Contact

Application for Membership

Complete Online Membership Form Below Or Download PDF Printed Version and Send In

Be sure to include the following whether you submit using the online form or you download the printed form to send in via email.

Curriculum Vitae
Two letters of recommendation from Active or Senior members of MSPS, one of which must be from the same geographic area as the applicant, except not a practice associate of the applicant.
Current Photograph
Application Fee of $300 (current year dues will be billed upon election to membership)
A copy of all current Board Certifications
A copy of your current valid active license to practice medicine in Florida
A letter of verification of staff privileges from a local Florida hospital
Verification of ASPS status

When all items have been received, your name will be circulated to the members of the Society, and your membership will then be voted on by the Executive Council of the Miami Society of Plastic Surgeons. An affirmative vote will activate your Candidate Status in the Society. If you have any questions or need any further information, please do not hesitate to contact us.

Prefer to download a membership form, scan it and send it in?

Download here:

Download Membership Form to Complete

Pay Your Application Fee Online

MSPS Online Membership Form Application

First Name:

Last Name:

Practice Name:

Office Address:

Office City:

Office State:

Office Zip Code:

Practice Email:

Practice Phone:

Practice Fax:

Practice Website:

Home Address:

Home City:

Home State:

Home Zip Code:

Home Phone:

Date of Birth:

Gender:

Male

Female

Undergraduate School:

Undergrad Yr to Yr:

Undergrad City:

Undergrad State:

Medical School:

Medical School Yr to Yr:

Medical School City:

Medical School State:

Internship:

Internship Yr to Yr:

Internship City:

Internship State:

Residency:

Residency Yr to Yr:

Residency City:

Resdiency State:

Plastic Surgery Residency:

PS Residency Yr to Yr:

PS Residency City:

Fellowship:

Fellowship Yr to Yr:

Fellowship City:

Fellowship State:

Other:

Other Yr to Yr:

Other City:

Other State:

Address & Situation Since Completion of Training:

Florida License Number:

Florida License Date Issued:

American Board of Plastic Surgery Date Certified:

Other Board:

Other Board Date Certified:

Additional Other Board:

Additional Other Board Date Certified:

Additional Other Board:

Additional Other Board Date Certified:

Please mark if you are an active member of the following:

ASPS

ASAPS

FMA

AMA

Other

Florida Hospital Appointments:

Has your license to practice medicine in any State, your license to prescribe drugs or your permit to dispense drugs, ever been revoked, suspended, restricted in any way, limited or voluntarily relinquished? (If so, please attach a separate report stating the date such action was taken, the name of the Agency, the case or matter number and give a precise description of the circumstances and the final action taken. )

Yes

Have you ever been notified to respond to or appear before a County or State Medical Society, Board or Committee of a hospital, any other Health Care facility on a complaint of any nature, including but not limited to unprofessional or unethical conduct and have been found guilty? (If so, please attach a separate report stating the date of actual notice, the organization or entity, and provide a detailed description of the circumstances and the nature of the complaint or charge and the final disposition)

Yes

Have your privileges at any hospital or other health care facility ever been revoked, suspended, limited involuntarily, denied or not renewed by such institution? (If so, please attach a separate report stating the date such action was taken, the name of the entity, description of the action taken, the basis given)

Yes

Has your license to practice medicine in any State, your privileges, either staff or clinical, ever been placed on probation and/or limited in any respect by such entity? (If so, please attach a separate report stating the date such action was taken, the name of the entity, the basis such action was taken, its duration and the date of termination if applicable. )

Yes

In the past 10 years, have you been found guilty of medical malpractice, or agreed to a monetary settlement of a malpractice claim? (If yes, please attach a separate report stating the date of such notice and/or suit, the name of the Plaintiff (s), the city and State of the Plaintiff's residence when under your care, the alleged basis for such a claim, and the disposition; if settled or if a verdict was rendered, the amount, the name of the Court having jurisdiction over the claim and the case number if suit was filed. )

Yes

Have you ever been treated by any health care provider, in a formal or practice setting or informally, for alcohol or any substance abuse, including narcotics, central nervous systems, stimulants or depressants? (If so, please attach a separate report stating the details and the outcome.)

Yes

If you operate on a patient, do you make yourself available by some form of answering service, the day/night that you have performed the surgery?

Yes

If you have a complication, do you have a hospital in which you are credentialed, where you can send your patient for further care?

Yes

Opt-In

By checking this box, I agree that the information in this application is provided for the purpose of obtaining membership in the Miami Society of Plastic Surgeons and, to the best of my knowledge, is accurate and complete. If this application is accepted and membership is granted, I agree that requesting and accepting such

membership. and continuing to maintain such membership, constitutes my consent to receive all communications sent by or on behalf of the Florida Society of Plastic Surgeons, Inc. and its subsidiaries and affiliates, via the communications vehicle of its preference, including but not limited to

Email, Fax, Telephone, Regular Mail, or special expedited mail services.

Opt-In

By checking this box, I authorize the Miami Society of Plastic Surgeons to consult with other organizations with which I have been associated, and with others who may have information bearing on my competence, character and ethical qualifications. I consent to the Society's inspection of such documents that may he material to an evaluation of my professional qualifications for membership, as well as my moral and ethical qualifications, and release from any liability all representatives of the Society for their acts performed without intentional fraud in connection with evaluating me and my credentials, and release from liability all individuals and organizations who provide information to the Society without intentional fraud concerning my competence, ethics, character and other qualifications for membership, including otherwise privileged or confidential information.

CV - Attach Here

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Letter of Rec. from Member of MSPS

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Current Photograph

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Board Certification 1

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Board Certification 2

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Board Certification 3

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