Become a Member

Pediatric Alliance of Central Texas dues are $50 per physician annually. You can submit this form below and pay online or you can choose to fill out our application (download PDF) and pay with check by mail. Please note: If you have multiple physicians in your group/practice each member needs to be entered separately.

Member Information


First Name:
Last Name:
Name Suffix:
E-mail Address:
Password:	Confirmation:
	(Password must include lower-case and upper-case letters as well as numbers)
Please identify your specialty of practice:
How long have you been in practice in the Austin/Central Texas area?:

Practice Information

Group/Practice Name:
Please select the type of practice that BEST describes your current practice:

Street 1:
Street 2:
City:

State:
Zip:
Main Number:	- -
Back Line Number:	- -
Fax Number:	- -
Website:
Nurse Coordinator:
Office Contact:
Special Instructions for Referrals:

Become a Member

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