Membership Application

Please complete the form below to become a member of AAPCE, the only national endoscopy organization for primary care physicians.

Already a member? Login Here

| denotes required field

Membership Types

Regular Primary Care Membership | $125.00

Associate Membership | $125.00

Resident Membership | $25.00

Your membership is good for 1 year after the date that you pay your membership dues. You will be notified for renewal before your membership expires. Your membership benefits will include: Membership in the only national endoscopy organization for primary care physicians, Networking with other like-minded primary care endoscopists, teachers, and researchers via an exclusive primary care endoscopy list serve, You will be supporting a national organization that is improving access to care through greater availability of competent primary care endoscopists and you will have access to CME specifically for primary care endoscopists.

If you would like to submit this form by fax, please submit it to: 913-906-6084

Download pdf version
Personal Information
First Name: Last Name:
Street Address1:
Street Address2:
City: State:
Zip Code: Home Phone:
Country:
Date of Birth (mm/dd/yyyy):
Gender: Male    Female
Ethnic Background (optional):
This is OPTIONAL and has no bearing or effect on a member's eligibility for membership or relationship with AAPCE. This information will be added to the member database profile.
Preferred Email Address::
Your email address will be your username to login and your password will be emailed to you upon completion of this form.
Business Information
Name of Institution/Private Practice:
Street Address 1:
Street Address 2:
City: State:
Zip Code:
Business Phone: Fax:
Business Web Site (optional):
Preferred Mailing Address: Business    Home
Professional Liability Insurance (optional):
Additional Annual Malpractice Premium for Endoscopy (if applicable): Total Annual Malpractice Premium:
Military Provider/Public Health Service
(Federal Tort Claims Act):
Federally Qualified Health Center
(Federal Tort Claims Act):
Other:
Criteria for Membership
Medical School
Graduation Date (mm/yyyy):
Residency Specialty:
Institution:
Date of Completion (mm/yyyy):
Residents should indicate anticipated date of completion
Specialty Board Certification:
Residents should indicate anticipated specialty and certification date
Initial Year of Certification (yyy):
Recommended by one regular AAPCE member. (If you do not know a current member of AAPCE but would still like to join, please contact us by email.)
Name:
List medical organizations in which you are a member:
Must maintain membership in a national organization representing the respective member's discipline or specialty field.
Endoscopic Experience/Commitment
Members must demonstrate commitment to endoscopic and/or gastrointestinal medicine in the primary care setting. If you do not perform endoscopy, please skip to the end of this section in order to indicate related publications/research/teaching experience.
Endoscopy that you perform (check all that apply):
Flexible sigmoidoscopy
Colonoscopy
Snare polypectomy
EGD
Nonvariceal hemostasis
Variceal hemostasis/banding
Esophageal dilation, bougie
Esophageal dilation, pneumatic
PEG placement
Esophagoscopy
Capsule endoscopy
Other procedure(s) (nasolaryngoscopy, etc):
Endoscopy training (check all that apply):
Residency
Fellowship
Formal procedure course*
Preceptor, Family Medicine
Preceptor, GI
Preceptor, Surgeon
* Please indicate name and length of course in "Other" box below.
Other training:
Years performing endoscopy: (not including residency training)
Total number of procedures:
Flexible signmoidoscopy:
Colonoscopy:
EGD:
Capsule endoscopy:
Current Privileges (check all that apply): Please indicate date that privileges where first established.
Flexible sigmoidoscopy    Year first obtained (yyyy):
Colonoscopy    Year first obtained (yyyy):
EGD    Year first obtained (yyyy):
Esophagoscopy    Year first obtained (yyyy):
Capsule endoscopy    Year first obtained (yyyy):
Conscious sedation    Year first obtained (yyyy):
Other:
Location where endoscopy is performed (check all that apply):
Hospital
Surgical/Diagnostic center (free standing)
Office
Other site(s):
Publications:
GI Medicine
Endoscopy
Other:
Research:
GI Medicine
Endoscopy
Other:
Teaching:
GI Medicine
Endoscopy
Other:
Resident Applicants Only:
Name of Residency Directory:
Email of Residency Directory:
THANK YOU VERY MUCH!: If you have any suggestions or comments regarding the application process, please let us know in the box below.
How did you hear about AAPCE?
Security Code
  BGGVGD
Enter Security Code: