CAPM :: Canadian Academy of Pain Management

Renewal New Member

Mailing Address:

Phone Work:
Phone Home:

Academic Degrees:

Hospital Affiliation:
Private Practice?	Yes No

Academic Appointment:

Please Choose from the following:

Physician

Physiotherapist

Registered Nurse

Psychologist

Occupational Therapist

Dental Surgeon

Pharmacologist

Social Worker

Chiropractor

Other:

Physician Members in Practice	$250
Active Members, non-physicians	$100
Contributing members (industry)	$1000
Students/members in training	$25

I hearby allow the above information to be published online on the CAPM website.

Payable To:

Canadian Academy of Pain Management
5734 Yonge Street, Suite 300
Toronto, ON.
M2M 4E7