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WVSRS Membership – Individual Physician

$50.00 / year

Dues payments are as follows:

Practice Dues: $150.00 – Sign-Up Here
Individual Physician Dues: $50.00

If your Practice does not cover your dues you may pay as an Individual. This will allow you and one staff member to attend.

Practice Dues cover up to 4 providers and 6 staff. If you would like to have additional staff to attend the meeting each year, an additional fee of $50 per person will be due.

Physician Name *

Physician Medical Designation *

WVSRS Annual Meeting (Physician)

WVSRS Annual Meeting (Physician) – Friday Reception

Yes, I will attend the Friday reception.

WVSRS Annual Meeting (Physician) – Saturday Night Event

Yes, I will attend the Saturday night event.

PRACTICE INFORMATION

Physician – Practice Name

Physician Phone Number *

Physician Email *

Physician Full Address *

101 Main St., Charleston, WV 23502

Physician Website

Physician Facebook URL

Physician Upload Logo or Photo

(max file size 64 MB)

Staff Member (1)

Staff Name

Staff Medical Designation

WVSRS Annual Meeting (Staff)

Additional information

Additional information

Type	Individual Physician Dues: $50.00

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