Please submit the following form to become a member of the Texas Society of Plastic Surgeons. You can also download our membership application for mail in.
If you are already a member, click here for renewal
Please review our membership requirements and levels. An application fee of $100 is required unless applying for Resident/Fellow membership. Upon submission of your application, you will receive correspondence regarding any additional paperwork needed and status of your application.
All required fields are indicated by *.
Name:
Texas License #:
Office Address:
Office Phone:
Home Address:
Home Phone:
Fax:
e-mail address:
Date of Birth:
Citizenship:
Spouse’s Name:
Medical Education (schools, years of attendance, graduation date):
Internship (place and dates):
Plastic Surgery (place and dates):
Fellowship (places and dates):
Date Certified by American Board of Plastic Surgery:
Board Eligible: Yes No
Plan to take Board Examinations (date):
Name and date of other board certification:
Hospital Staffs:
Teaching Staff Appointments:
Sponsors: Please list three Active TSPS members who may be contacted regarding your application.
1)
2)
3)
