Renewal Order Form

MedLicense.com

Professional Medical Licensure in all 50 States

770.456.5932 info@medlicense.com

Renewal Services Order Form

$190 per license per renewal cycle

Name: *

Mailing Address: *

Phone: *

Email Address: *

Date of Birth: *

Social Security Number: *

List All States to Renew: *

List All DEA #s to Renew. You must provide the DEA #, the Expiration Date, and the Zip Code on the Certificate: *

List all State CSR/CDS Drug Permits to Renew. You must provide the State, the full #, Expiration Date, and Address listed on the Certificate: *

Will any of the Medical Licenses, DEA, or State CSR/CDS Drug Permits listed above expire within 90 days of today? If so list them below along with their expiration date: *

Yes

List all States, DEA, and State CSR/CDS Drug Permits which will expire within 90 days along with the Expiration Date: *

Have you been arrested since your last renewal? *

Yes

Have you been disciplined, placed on probation, or had employment or privileges restricted in any way since your last renewal? *

Yes

Since your last renewal have you ever had any notices from any Medical Board concerning your Medical License? This includes complaints, investigations, disciplinary actions, probation, suspensions, revocations, and etc. *

Yes

Since your last renewal have you been notified that a malpractice complaint was filed against you (no matter the final status)? *

Yes

Since your last renewal have any malpractice complaint resulted in a settlement, judgment, or dismissal? *

Yes

Since your last renewal have you been treated for substance abuse? *

Yes

Since your last renewal have you been treated for any Mental Illness (including depression) *

Yes

Since your last renewal have you been out of practice for more than 6 months? *

Yes

Since your last renewal has any negative action occurred which might need to be reported to a Medical Board? *

Yes

Credit Card Number: *

Expiration Date: *

3 / 4 digit Code *

Name on the Credit Card: *

Billing Address of the Credit Card: *

I understand that when I submit my order that my credit card will be charged $190 for each medical license, DEA number, State CSR/CDS permit which I list above. I authorize this charge. *

I agree to the terms listed above

After you submit your order, you will receive an email from MedLicense.com providing our welcome packet for new Renewal Clients within 24 hours.

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