Please Tell us about your Large Urology Group!

If your group has ten or more urologists, the LUGPA needs to know about you! Collecting this information is critical to our efforts; only by identifying as many large groups as possible can the LUGPA realize its full potential to enhance the activities of large urology practices. So please respond; it only takes a moment.

Please fill out our online form below, or use our downloadable pdf form and fax us your large group information.
 

Practice Information

Name of Corporation:* (the legal name of your large urology group practice)
       
Number of Urologists in your Large Urology Group Practice:*
Number of Offices in your Large Urology Group Practice:*
Potential expansion to include offices and urologists, expected (date)
       
Corporate Mailing Address: (the mailing address of your corporate headquarters)
Address 1:*   Address 2: City:*
       
State: Zip/Postal Code:* Country: Phone:*
       
Fax: Corporate Website Address:  
 
       

Corporate Contact (Chief Operating Officer or its equivalent)

First Name: Middle Name: Last Name: Degree(s):
       
Work Title: Phone: Email:  
 
     

Individual Urologist Information
First Name:* Middle Name: Last Name:* Degree(s):
       
Email:*      
     
       
Practice Mailing Address: (where you would like to receive mail or other correspondence)
Address 1:*   Address 2: City:*
       
State: Zip/Postal Code:* Country: Phone:*
       
Fax:      
     
       
   
If you would like an email confirmation of the information you have provided, please enter an email address below to send the confirmation to:
     
   
 
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