Online Membership Application

Please complete the form below to submit your application for membership of the Primary Care Dermatology Society of Canada (PCDSC). Please ensure to complete all fields that are required. Any questions, please contact the PCDSC office at 604.988.0450 or email info@pcdsc.ca.

STEP 1 – Account Information

STEP 2 – Personal Information

Please type your name and credentials the way you would like it to appear on your certificate of membership.

Prefix: Dr.

First Name (required)

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Last Name (required)

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Credentials (required)

(MD, MB ChB, BSc, CCFP, CFPC, FCFP)

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(MD, MB ChB, BSc, CCFP, CFPC, FCFP)

Specialty (if available)

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Physician License Number (required)

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Practice/Clinic Name

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Address (required)

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City (required)

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Province/Territory (required)

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Postal Code (required)

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Telephone (required)

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Email Address

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Fax (if available)

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Website (if available)

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STEP 3 – Additional Information About Yourself

Physician Locator

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The College of Physicians and Surgeons

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Gender

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Date of Birth (required)

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Medical School of Graduation (required)

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Graduation Year (required)

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Degree (required)

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Year You Started Practicing Dermatology (required)

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Do You Practice Dermatology?

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How Did You Hear About PCDSC?

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STEP 4 – Billing Information

Billing Address Same

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Billing Address

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Billing City

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Billing Province/Territory

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Billing Postal Code

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Billing Telephone

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Billing Fax

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Billing Email

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Terms of Service (required)

Cancellation Policy: Cancellation must be received in writing at the PCDSC office.

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Cancellation Policy: Cancellation must be received in writing at the PCDSC office.

Privacy Policy (required)

Privacy Policy

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Privacy Policy