Apply for Membership

CIMA Membership Application

Please use the online form below to apply for CIMA Membership.

This application form is for new memberships. If you are an existing CIMA Member, please complete the Membership Renewal Form.

Email inquiries pertaining to membership should be sent to info@cimadoctors.ca

Choose a Username*
First Name*
Last Name*
Title
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Provincial college license no.*
Clinic Name (optional)
Clinic Website (optional)
Type of medical practice including special interests (e.g. family practice, special interest acupuncture)
Would you like your name on a list accessible by members only?*
- Yes
- No
Would you like your name on a list accessible by the public?*
- Yes
- No
Do you consent to receiving emails from CIMA regarding upcoming events and updates about the organization?*
- Yes
- No
Would you like to be involved in the administration of CIMA (e.g. director, organizational, media liaison, website management, educational programs, provincial representative)?*
- Yes.
- No.
If yes, in what capacity? (See above: Director, organizational, etc.)
Do you have any comments or suggestions on the goals and targets of CIMA?
Membership
Total
$ 0.00 CAD
Credit Card
Card Details
Cardholder Name