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OMDA - The Ohio Society for Post-Acute and Long-Term Care Medicine
Membership Application
October 28, 2022 - December 30, 2022
Prefix
First Name:
Last Name:
Suffix:
Credentials:
Title:
Facility:
Email:
Phone
Alternate Phone
Mailing Address:
Business
Home
Organization
Address:
City:
State
Zip
I serve as a:
Physician MD/DO
Advanced Practice Nurse NP/CNS
Physicians Assistant
Nurse RN/LPN
Dietitian/RDN
Pharmacist
Social Worker
Therapist OTR/PT/SLP/COTA/PTA
Administrator ED/DON/ADON
Industry/Corporate Professional
Fellow
Resident
Intern
Student
Other
I am a Certified Medical Director (CMD):
Yes
No
I have served as a Medical Director for
years.
How did you learn about OMDA?
Membership Dues
Physician
Complimentary Membership until December 30, 2022
PRIVACY: Contact information and personal information collected during application process will be shared only for OMDA purposes. Some membership information will be listed in the membership directory accessible only to members.
Contact us: jeannine@ohiomda.org or 614-570-8474
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