User account

Licensed medical doctors (M.D. or D.O.) who have successfully completed their ophthalmology residence may apply for membership by submitting a completed application form.

Account information

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

1-Personal Information

First Name: *

Please enter your first name

Middle Name:

Please enter your middle name (optional)

Last Name (Surname): *

Please enter your lastname/surname

Suffix:

Please enter any suffix to your name (Jr., Sr., III, IV, etc.)

Degree: *

Please select your degree

Home Address:

Home Address

Home Address 2:

Second line of home address (if needed)

Home City:

City of Home Address

Home State:

State of home address

Home ZIP or Postal Code:

ZIP or Postal Code of Home Address

Home Phone:

Home phone number

2-Office Information

Office Address: *

Office Address

Office Address2:

Office address, line 2 (if needed)

Office City: *

City of office

Office State: *

State where office address is located

Office ZIP or Postal Code: *

ZIP or postal code

Office Phone: *

Office phone number (please use format (###)###-####)

Office FAX Number:

Office FAX number (please use format (###)###-####)

Office Website:

Website of your practice, office, or group

3-Professional Information

Residency Location:

Location where residency completed The content of this field is kept private and will not be shown publicly.

Residency Dates:

Dates of residency The content of this field is kept private and will not be shown publicly.

County Medical Society Membership:

County medical society(ies) of which you are a member The content of this field is kept private and will not be shown publicly.

Recommending Member #1:

Recommending member of DAO The content of this field is kept private and will not be shown publicly.

Recommending Member #2:

Recommending member of DAO The content of this field is kept private and will not be shown publicly.

Sub-Specialty: *

Pick your sub-specialty (required field).

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