Physician Membership Application

To apply for KMS membership, please complete the form below. 

After we review your application, our staff will follow-up with your dues statement. Your membership will become active once all membership-related queries are fulfilled and payment is received. (Information on membership dues may be found here.)

• If you practice in Sedgwick county, please contact the Medical Society of Sedgwick County for membership information. They can be reached at 316.683.7557.

Physician Membership

First Name *

Middle Initial *

Last Name *

Suffix *

Gender *

Male

Female

Degree *

MD

DO

Date of Birth (mm/dd/yy) *

Email *

Medical School *

Kansas License Number *

Practice Information

Practice Name *

Full-time academic medicine? *

Yes

No

Office Address *

Office City, State Zip *

Office Phone *

Specialty *

Home Address

Home Address *

Home City, State Zip *

Home Phone *

Preferred Address *

Practice

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Anti-Spam

Anti-spam Captcha *

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