Member Information Form | Maine Medical Association

Name

Suffix

MD

DO

Other

If other selected above, please indicate title here:

Gender

Date of Birth

Specialty

Subspecialty

Employer/Practice Name

What is the ownership of your practice?

Solo private practice

Partner in private Physician group

Employed by a Physician owned group

Employed by a hospital

Employed by a Federally Qualified Health Center

Retired

Resident

Medical Student

Other (list below)

Describe other ownership (if "other" selected above)

Business Email

Personal Email

Which email would you prefer the MMA use for member communication? (select one)

Personal Email

Business Email

Office Address

Office Phone

Cell Phone

Practice Website Address

Home Address

What social media do you utilize?

How do you prefer that MMA communicate with you? (select all that apply)

U.S. Mail

Email

Which of the following are you interested in? (select all that apply)

Public Health

Legislation of interest to physicians

Legislation of interest to my specialty

General trends in Medicine

Physicians Wellness or Medical Professional Health Program

Other (list below)

Describe other interest (if selected above)

Do you currently receive Maine Medicine Weekly Update, sent electronically each Monday from MMA?

Yes

No

I don't know

Do you receive the quarterly printed publication, Maine Medicine?

Yes

No

I don't know

Would you prefer receiving Maine Medicine electronically?

Yes

No

Have you ever utilized the MMA website at www.mainemed.com?

Yes

No

Would you be interested in serving as Doctor of the Day at the Legislature?

Yes

No

Would you be interested in serving on a committee?

Yes

No

Would you be willing to contact your legislators, state or federal, on an issue of importance to your specialty?

Yes

No

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