Membership Application

Membership

Membership category

Active Membership Practising physicians New members $75 · Returning $250 Full Life Membership Retired physicians, or age 70 and over $50 per year Resident Membership Physicians in residency training Complimentary Medical Student Membership Currently enrolled medical students Complimentary

Membership status

New member Returning / reinstating member

Personal & contact information

We’ll use these to confirm your application and reach you about your membership.

First name

Last name

Email address

Preferred telephone number

Professional information Optional

Medical students and residents: fill in what applies and skip the rest.

CPSO registration number

Year registered with CPSO

Medical school

Graduation year

Degrees / professional designations

Type of practice / specialty

Do you have hospital privileges?

Yes No

Hospital affiliation(s)

Languages spoken

Special clinical interests (up to three)

Practice limitations / scope of practice

For example: adults only; no obstetrics.

Practice information Optional

Where you see patients. Skip this section if you’re not in practice yet.

Practice / office name

Office street address

City

Province

Postal code

Office telephone

Office fax

Is your office wheelchair accessible?

Yes No

Referral & patient information Optional

Helps colleagues know when and how to refer to you.

Are you currently accepting referrals?

Yes No Limited / by consultation

Are you currently accepting new patients?

Yes No Limited / waitlist

Referral form

If you use a referral form, share it as a PDF or a link.

Upload a PDF Link to a web page No referral form

Referral form (PDF, up to 5 MB)

Referral form web address

Referral instructions / criteria

Preferred referral contact information

I authorize HAM to include my professional contact information, specialty, clinical interests, languages, practice limitations and hospital affiliations in its secure members-only directory. I authorize HAM to share my referral information, referral form and patient acceptance status with other HAM members. I would like to receive HAM news, education opportunities and member communications.

I confirm that the information provided is accurate and agree to the terms of HAM membership.

Membership fee

CategoryFee

Active Membership, new member $75 introductory first-year rate
Active Membership, returning member $250 per year
Full Life Membership $50 per year
Resident Membership Complimentary
Medical Student Membership Complimentary

After you submit, you’ll see the fee for your membership and, where there is one, a secure payment link.

Your application goes straight to the HAM office.

1 Membership

2 Personal & contact information

3 Professional information Optional

4 Practice information Optional

5 Referral & patient information Optional

6 Directory permissions & declaration

7 Membership fee