Join Us

We invite you to join the CPMS by completing the online application below.

If you have any questions, you may contact the Calcasieu Parish Medical Society office at 337-478-3780 or email us at calparmedsoc@yahoo.com.

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Calcasieu Parish Medical Society

Physicians Committed to Quality in Medical Care

Membership Application

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PERSONAL INFORMATION

Last Name (as shown on medical license) *

First Name *

Degree *

Birthplace *

Date of Birth *

Gender *

Home Address *

City *

State *

Zip *

Phone *

Fax *

Email *

Marital Status *

Spouse’s Name *

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PROFESSIONAL/PRACTICE INFORMATION

Louisiana License Number *

Other State Licenses *

ME # (if known) *

NPI # *

Practice Name or Group (If Applicable) *

Primary Specialty *

Subspecialty

Primary Practice Address *

City *

State *

Zip *

Preferred Mailing Address *

Home
Office

Practice Phone *

Practice Fax *

Email *

Website *

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Undergraduate College *

Degree *

From *

To *

College Address *

City *

State *

Zip *

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Medical School *

From *

To *

Medical School Address *

City *

State *

Zip *

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Intern/Residency (Hospital) *

Specialty *

From *

To *

Residency Address *

City *

State *

Zip *

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Fellowship

Specialty

From

Fellowship Address

City

State

Zip

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Military

Branch

From

Address

City

State

Zip

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Previous Practice (Employer)

From

Address

City

State

Zip

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Medical School Teaching Appointments

Professorship Level

From

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MEMBERSHIP APPLICATION PROCESSING

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Recommendations (Requires 2)

Below are the names of two CPMS members who may be contacted to provide letters of recommendation.

First Name *

Last Name *

First Name *

Last Name *

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If membership has been recommended to you by a CPMS member, please list his/her name below.

First Name *

Last Name *

Select Dues to be Paid *

Membership ($350)
Associate Membership ($175)
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I will pay by check

The information provided on this application is deemed to be true and complete. *

Billing Address

Calcasieu Parish Medical Society

Membership Application

PERSONAL INFORMATION

PROFESSIONAL/PRACTICE INFORMATION

MEMBERSHIP APPLICATION PROCESSING

Recommendations (Requires 2)

Not yet a member? Complete the online application and join today.

Not yet a member?
Complete the online application and join today.