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Have a proposal for FOGS or looking for a service?
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Thank You!
FOGS and the Florida Section ACOG recognize their corporate supporters
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Liability Issues Report
Please use this form liberally to report the related practice problems you are facing
The Form

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On Call Medical Coats
FOGS has teamed up with On Call Medical Coats to offer our members quality embroidered labcoats
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FOGS Endorsed Malpractice Carrier offering a 5% discount to FOGS members
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Lubell & Rosen
FOGS Endorsed
Pre-Paid Legal Defense
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Your practice could receive a dividend of up to 24.8% of your workers compensation premium.
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FLORIDA OBSTETRIC AND GYNECOLOGIC SOCIETY
Membership Application

Your Information:

Full Name:
Title:
Address:
City:
State:	Zip:
County:
Phone:
Fax:
Email:

Staff Privileges:

Institution	City

Education and Training:

Medical School	Grad Year	Degree

Professional and Postgraduate Training:

Program Name	Type	Specialty

Have your hospital privileges ever been revoked or curtailed?
No Yes

Number of Years at Present Location:

Is your practice both Obstetrics and Gynecology?
No Yes Gynecology Only? No Yes

Are you a diplomate of the American Board of Ob/Gyn?
No Yes Efective Date:

Are you a Fellow of the American College of Ob/Gyn?
No Yes Efective Date:

Are you a member of the Florida Medical Association?
No Yes

by checking this box, you indicate that all information provided is complete true to the best of your belief.

Application fee:	$50.00
First year Dues:	$195.00
Total Charges:	$245.00

Card Type: Please Select Visa Master Card Aerican Express Card Number:
Expiration:

Validation:

Enter the code displayed in the image at right into the box on the left.