Whole Group Initial Enrollment

Please submit this form to create IACP's record for your Practice Group

Primary Contact for Group

This should be the person who will receive renewal reminders and other administrative communications about the Whole Group membership for your Practice Group.

First Name *

Last Name *

Email *

Preferred Salutation *

Examples: Dear Bob - Hello Alice - Hola Dr. Martin

Phone

Additional Details

Practice Group *

Group Logo

Group Street Address *

Group City *

Group State or Province *

Group Postal Code *

Group Country *

Group Website

Members Included

Number of Whole Group Members *

List of Approved Members - Excel or CSV *

IMPORTANT: File MUST include Name, Email, and Profession for each member