Ultimate Doctor Membership Survey Form

MEDICAL PROVIDERS LISTING REQUEST

Request to become a CSTAR International Partner! This Ultimate Doctor's Membership creates a premier partnership between you and CSTAR International with many benefits included in your membership fee. Your yearly membership includes:

Exclusive surgical coordination rights as a CSTAR Partner Doctor. All patients we coordinate for are only placed with one of our partner doctors and recovery facilities.
Monthly Promotion on our social media
Entrance to all our events- come to any of the CSTAR International events for free
Expanded bio on our site and in our magazine
Publication and promotion of 1 article per month-Article guidelines included.
You will receive custom CSTAR scrubs that you should wear for your videos (Upon first surgery with us)
Once we are able to again, we will be organizing meet and greets in NYC throughout the year with 2-3 doctors at a time (in different specialties) for patients to meet the doctors and recovery facilities and have a question and answer session. By signing up with our platform, you have the option to participate and agree to also promote the events on your own social media.

ABOUT YOU

Title

First Name:

Middle Name:

Last Name:

Email:

Job Title:

MEDICAL BACKGROUND

Provide your Medical Background Information

CREDENTIALS AND BOARD CERTIFICATION *

Please provide your certifications and credentials.

Upload Your Permit to Practice *

Business Address

Apt, suite, etc.

Country

City

State

Zip code

If you work out of a specific clinic or own your own, please put the address.

Main Number:

Website:

Languages you Speak

How Long Have You Been Practising?

Have you ever been the subject of a lawsuit during the years you have been practising your profession? *

Yes

If Yes, Please Explain the Reason and what the outcome was.

Social Media

Please list all the social media accounts you are most active on.