2026 Membership Application

Basic Contact Information

First Name
Last Name
Title
Suffix
Email

Company Information

Company Name
Address
City
State
Zip
Work Phone
Work Fax
Website

Directory Listing Opt-Out

Please indicate if you wish to OPT OUT of having your Company information listed in the VAH-O membership directory. Note: the directory will NEVER contain your home address.
I wish to OPT OUT of having my information in the VAH-O Directory

Personal Address

Address
City
State
Zip
Cell Phone

Primary Address

Please choose the ONE address in which you wish to receive all VAH-O correspondence.
WORK Address is Primary Address
PERSONAL Address is Primary Address

Membership Information

Group

Dues: Up to 10 physicians $750(Small), 11-25 physicians $1,000 (Medium), 26+ physicians $1,500 (Large). All affiliated allied health professionals are complimentary.
Licensed physicians and allied health professionals including but not limited to registered nurses,nurse practitioners, clinical nurse specialists, pharmacists, physician assistants, administrators, socialworkers, and office managers in an oncology practice or university.

Regular

Dues: $100
Licensed physician caring for patients with cancer.

Allied Health Professional

Dues: If affiliated with a Group, Complimentary. If not affiliated with a Group, Dues: $50.
Healthcare staff person including but not limited to registered nurse, nurse practitioner, clinical nurse specialist, pharmacist, physician assistant, administrator, social worker, and office manager.

Fellow

Dues: Complimentary
Physician enrolled in subspecialty training program to care for patients with cancer.

Retired

Dues: Complimentary
Former physician or allied health professional who is no longer practicing.

Please choose your membership level:

Membership Level

If you indicated 'Group' above please select which Group:

Group
 Other

Physician Information

Please provide the following information for each Physician you wish to include in your Group Membership:
 - First Name
 - Last Name
 - Designations
 - Email Address
 - Practice Address
   - denotes required fields