"*" indicates required fields Who is your Physician?*Bart Price, MDPetra Travnicek, MD, FACPYour Name* First Middle Last DOB* MM slash DD slash YYYY Email* Primary Phone*Spouse (If Joining) First Middle Last DOB MM slash DD slash YYYY Spouse Email Spouse Primary PhoneChild 1 (If Joining) First Middle Last DOB MM slash DD slash YYYY Child 2 (If Joining) First Middle Last DOB MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Annual membership per person $5,000.00How many people are you renewing a membership for?*1234Payment Frequency* Annually Semi-Annually Quarterly Payment Method* Electronic Debit from Checking or Savings Mailing Check Mastercard/Visa American Express Discover TotalElectronic Debit from Checking or SavingsName on CheckBank Account NumberBank Routing Number from CheckCredit Card PaymentCardholder NameCredit Card NumberExpiration DateCVV2 Number
